Coroner delivered a narrative verdict and said the infection wasn't diagnosed because of a combination of 'unfortunate events and circumstances'

said the evidence was 'not definitive'

Suggestion Stanley's condition was caused by his recent circumcision was disputed by his mother and the

The most likely source of the deadly infection were boils found on his thigh

Two months later back in Britain he went into septic shock and died

Stanley underwent the procedure in Zimbabwe during the summer holidays

Stanley Chola, 10, from Whitley, Berkshire underwent a circumcision in Zimbabwe during the summer holidays

There were 'missed opportunities' to save a 10-year-old from an infection possibly caused by a circumcision carried out in Africa, an inquest heard today.

Stanley Chola, 10, from Whitley, Berkshire underwent the procedure in Zimbabwe during the summer holidays.

Nearly two months later on October 13, 2013 he went into septic shock and died in hospital.

At the time it was thought the infection might have been caused by an injury to his knee, either from being hit with a hockey stick by another pupil or while playing football.

However, a leading doctor said the two theories were 'very unlikely' to be the case.

Today, a coroner delivered a narrative verdict of Stanley's death, and said that the fatal infection had not diagnosed because of a combination of 'unfortunate events and circumstances'.

Stanley, a pupil at New Christ Church School in Reading, Berkshire, went with his family to Zimbabwe during the summer holidays last year and was circumcised on August 23.

However, he was absent during the first week of the new term and his step-father, Malik Issa, told a member of school staff this was because he had developed an infection from the circumcision.

On October 7 his mother, Ellen Gomes, took Stanley to the Royal Berkshire Hospital in Reading, with her son complaining about a knee problem caused while playing football.

The inquest heard the injury may have been caused by another pupil hitting Stanley with a plastic hockey stick.

The inquest heard Ms Gomes took Stanley to a GP again the following day, but there appeared to be no reason for major concern.

On October 11 his mother spoke to a doctor over the phone and told them Stanley had developed a chesty cough, abdominal pains and was not eating.

She also said he was suffering from vomiting and diarrhoea.

Stanley was prescribed antibiotics and the doctor said the information his mother had given did not suggest he needed to be seen in person.

At around 4.40am on October 12, 2013, paramedics were called to the family's home in Laburnum Gardens in Whitley, after a call to say Stanley was unable to walk because of his knee pain.

Discussing the possibility that the circumcision was the cause of Stanley's death, the Coroner said: 'That evidence is, I think, at best confusing. It is certainly not definitive. That is the less likely explanation'

The paramedics said he was able to walk but that his breathing and oxygen saturation level were unusual and that Stanley also had a slight temperature.

An appointment was arranged for the boy to see a doctor at 8am the next morning, but he did not attend.

Dr Lade said: 'This was a pivotal moment in Stanley's case because had he been seen by a doctor that Saturday morning and appropriate treatment and investigations taken place, he might have been saved.'

When Stanley did not attend his appointment, the Westcall service would normally have contacted the family, but a systems failure that day and the fact they could not find a number for Ms Gomes, made this impossible.

The next day a paramedic was scrambled to the family home at around 7.40pm after Stanley started having breathing difficulties.

His right calf was described as very firm and swollen and the paramedic found marks on his thigh, which his mother said were healing boils.

On arrival at the Royal Berkshire Hospital, doctors diagnosed Stanley with septic shock and said his chances of survival were slim.

His condition rapidly deteriorated and doctors twice performed CPR before Stanley was declared dead at 11.35pm.

Dr Lade told the inquest it was not uncommon for children with sepsis to die very quickly.

The inquest heard that the boils on Stanley's thigh could have been caused by the circumcision infection and Dr Shabnam Iyer, a microbiologist who helped with the post-mortem examination, said the infection could have spread from the skin and into Stanley's leg.

Coroner Peter Bedford said when Stanley's mother told an out-of-hours doctor over the phone that her son had developed vomiting, abdominal pain and diarrhoea, he should be been sent for a physical examination.

However, Mr Bedford added that the nature of the infection would still have made diagnosis difficult.

Pathologist Steven Gould told the inquest that the most likely source of the deadly infection was boils found on his upper thigh.

The inquest was also told that there was no evidence of Stanley being attacked, with police investigating the matter after suggestions he was hit with a hockey stick prior to his death.

Delivering a narrative verdict, Mr Bedford said that despite Stanley being seen by various healthcare professionals, they had not diagnosed his 'serious and developing' infection because of a combination of 'unfortunate events and circumstances'.

Mr Bedford added: 'It is likely that the source of Stanley's fatal infection was boil-type lesions that developed in skin tissue and caused cellulitis in the right leg and then spread through the venous system into the lung.

'There were missed opportunities to admit Stanley to hospital earlier than October 13.

'However, the virulent nature of the fatal infection and the difficulty in diagnosis because of the gradual onset of symptoms makes it uncertain, in my view, that earlier diagnosis would have affected the outcome.'

Discussing the possibility that the circumcision was the cause of Stanley's death, which is disputed by his mother, Mr Bedford said: 'That evidence is, I think, at best confusing. It is certainly not definitive. That is the less likely explanation.'

Dr Gould said there remained unanswered questions about exactly where the infection came from.

'We believe that this particular organism spread from the boils and settled in this area in the knee,' Dr Gould told the inquest. 'I have never seen that before. It is highly unusual.'

Speaking after the inquest, his family said they would wait until they had received the coroner's report and spoken with their lawyer before deciding what further action to take.

Ms Gomes said: 'He was a lovely boy, a very happy boy.

'It is one year this month that Stanley has been away from his mother.'