The damning report into the treatment and subsequent death of Indya Trevelyan concluded the probability of her dying could have been “very considerably reduced.”

The report's authors said Brighton and Sussex University Hospital NHS Trust needed to assume a collective corporate responsibility for the shortcomings they had found.

Specialists Gavin Morrison from Guy's Hospital and Adrian Lloyd-Thomas from Great Ormond Street Hospital carried out the report after a coroner raised question concerns about the 20-month-old's care at the Royal Alex Children's Hospital in Brighton.

During an inquest into the death in October last year the court was told how crucial neck ties, that would have helped keep the tube in place, were not used and anaesthetist David Campbell, who was left in charge of Indya, was not warned of their absence.

Brighton's Deputy Coroner John Hooper pressed for an external investigation of the trust to be carried out, the results of which were published this week.

Referring to the 12-hours delay in examining the X-ray the report states: "It is a matter of concern that this chest X-ray does not appear to have been reviewed shortly after it had been completed, as this information, when combined with the lack of clinical improvement, might have triggered an earlier referral.

"Furthermore there appears to be no system of regular patient assessment."

The investigation also focused on the absence of the crucial neck tapes to keep the breathing tube secure.

It states: "There was no attempt to secure the tracheostomy tube with tapes."

It added: "Established paediatric standard of practice includes use of tracheostomy tapes... tapes should have been employed and applied round the neck before the surgeon left the theatre."

And concluded: "It was out with normal standard of practice for the surgeon to leave the theatre without first checking the security and adequacy of the tracheostomy tube with the patient in a neutral position."

The investigation also questioned the training given by the trust to lead surgeon Mr Anthony McGilligan.

It states: "In appointing Mr McGilligan as paediatric ENT lead two years ago, the Trust has a commitment to ensuring he has or had appropriate sub-speciality training.

"They believed that his paediatric training whilst a specialist registrar together with a one month observership at Great Ormond Street Hospital had met this need.

"The reviewers feel that by observing for such a short period and actually not undertaking surgery under supervision, he was left exposed."

They added: "The lead ENT surgeon in Paediatric ENT in the RACH, should have undertaken a minimum of four months working (not simply as an observer) in a tertiary unit managing paediatric airway disease."