The devastated parents of a baby who died after being sent to the back of a queue in a GP surgery want to stop other children “slipping through the net”.

Axel Peanberg King was just seven weeks old when he stopped breathing while waiting for a doctor at the Harmoni Centre at the Whittington Hospital in Highgate.

He was treated only when an off-duty nurse spotted his condition – but by then it was too late.

A two-day inquest into his death ended last Thursday (February 28) with Inner North London coroner Dr Shirley Radcliffe branding the initial telephone referral from Harmoni “wholly inadequate” with “insufficient questions”.

Now Axel’s parents, Linda and Alistair, are considering action to stop the same fate befalling other children.

In a statement, they said: “We believe there are still many questions to answer about the safety of the service provided by Harmoni.

“We do not believe that anyone hearing all the evidence in this case could have full confidence in Harmoni’s out-of-hours services.

“We are now considering all our options to prevent any other children from falling through the net.”

The inquest at St Pancras Coroner’s Court heard how Axel was diagnosed as having a probable viral infection by the family doctor in October.

The next night he had not improved and his 35-year-old mother was visited by a Harmoni doctor who said baby Axel’s vital signs were good.

She and Mr Peanberg King, 36, who live in Islington, called Harmoni the following day. But when Dr Muttu Shantikumar called them back he made them a routine appointment.

Coroner Dr Radcliffe said this should have been urgent.

Axel stopped breathing as Mrs Peanberg King sat in the waiting room and, when she rushed to the front of the queue, the receptionist allegedly told her to wait her turn.

An off-duty paediatric nurse then raised the alarm but it was too late.

Recording a narrative verdict, Dr Radcliffe said she was satisfied that the first two doctors’ consultations were carried out in an appropriate manner, but the telephone medical assistance the couple had was “wholly inadequate”.

She said: “It lasted only one minute and the entries made are clearly at odds with the evidence from Mrs Peanberg King.

“It is impossible to say whether intervention at an earlier stage would have changed the tragic outcome.”

Dr David Lee, medical director for Harmoni, said the company would be taking full regard of the coroner’s findings.

He said: “The death of such a young child is always a particularly traumatic experience for all concerned. In response to this we have undertaken an exceptionally detailed review of the circumstances.”

He added: “We have jointly assessed how we can provide additional support to our out-of-hours GPs dealing with very young babies and have further improved communication between the services so that if there are concerns these can be highlighted and addressed quickly.”

Harmoni came under fire last year after a sick newborn baby was left to wait for more than an hour in a late-night GP surgery on Christmas Eve – only for the parents to be told the doctor had already gone.

In January, Harmoni bosses were hauled in front of Islington Council after Fred Kavalier, a former lead clinician at the company, resigned and wrote to directors about his “urgent concern about the quality and safety of the service”.