A two-year-old boy died from meningitis after a 999 operator couldn't properly understand his Czech Republic parent's English.
As a result, the operator wasn't able to assess how serious little Dusan Spivak's condition was and so the call got 'lost in the system'.
The parent was referred to NHS Direct which resulted in a paramedic not being sent out until it was too late to save him.
Dusan was rushed to the Royal Derby Hospital an hour and a half after his parents called the emergency services - but by then medics said it was too late to save his life.
An inquest heard how Dusan's family, originally from the Czech Republic, had dialled 999 at 10.26pm on May 29 last year after a large rash formed quickly on the youngster's belly at their home in Normanton, Derbyshire.
Michelle Summonds, acting service delivery manager for East Midlands Ambulance Service (EMAS), said that because none of the family members spoke English, it was 'difficult' for the call handler to determine how serious the incident was.
She admitted the call handler failed to source an interpreter, which meant he did not grasp how serious the situation was.
As a result, he wrongly chose to involve NHS Direct, when it was the EMAS Clinical Assessment Team - which deal with more urgent 999 calls - which needed to be sent details. He also failed to complete the referral form to NHS Direct.
The inquest at Derby Coroner's Court heard a second 999 call, which was properly handled, was made at 10.50pm and led to a paramedic arriving at the scene at 11.29pm.
Assistant deputy coroner Paul McCandless, ruled that had the first 999 call been handled correctly, a paramedic would have arrived approximately 13 minutes earlier.
Dr William Carroll, who led frantic efforts to save the youngster told the inquest the boy had developed meningococcal septicaemia - a life-threatening infection brought on by meningitis.
He said it was a condition that can bring about death very quickly and that 'every minute counts'.
Asked if Dusan would have lived had he arrived at hospital sooner, Dr Carroll replied: "Probably, yes."
In delivering his verdict, Mr McCandless said Dusan had fallen victim to a condition that was every parent's and medic's 'worst nightmare'.
Afterwards, a spokesperson for EMAS said it was 'sorry for the error in the categorisation of the call', and that action had been taken to prevent the incident happening again.
Read more: Meningitis symptoms