Aarav Chopra suffered a “prolonged” cardiac arrest which was triggered by a build up of blood in his chest cavity and died on November 22, 2023.
Months earlier Aarav had undergone a liver transplant but his body was rejecting the organ so he was having tests at Birmingham Children’s Hospital.
The youngster was having a routine liver biopsy when a trainee doctor pierced an artery with a needle.
Aarav, of Wolverhampton, died as a result of serious brain damage as doctors spent nearly 30 minutes trying to resuscitate him.
An inquest heard his condition went “undiagnosed and untreated” during the procedure.
Senior Coroner Louise Hunt also criticised “poor planning” by staff before the biopsy.
In her report, she said there was “poor” communication about the bleed Aarav suffered, “all of which hampered treatment after his collapse”.
She also highlighted “confusion around the experience of the trainee doctor performing the biopsy”.
The inquest heard the trainee was thought to be a year six but was only in year four of his training.
Aarav's parents were also unaware a trainee would be performing the biopsy on their son.
Mrs Hunt also raised concerns that an internal meeting following Aarav's death was “contributed to by neglect”.
Mrs Hunt has now issued a Prevention of Future Deaths report calling on Birmingham Women’s and Children’s NHS Foundation Trust to set out what action it will take.
Dr Satish Rao, Chief Medical Officer at the trust, said: “We offer our sincere condolences to Aarav's family and loved ones.
“It’s clear from the findings of this inquest, along with those from an investigation conducted by the trust last year, that the standard of care provided did not meet those expected and, for this, we are truly sorry.
“Following the inquest, and our own review in 2024, changes were made to our processes to improve patient care.”
Aarav had a condition called biliary atresia, which meant bile flow out of his liver was blocked.
He underwent a liver transplant on August 15, 2023 but suffered...