Austin Facer's mother remembers him as a "joyful little boy who loved life".
NSW deputy state coroner Elizabeth Ryan said his family may now spend years wondering whether that life could have been saved.
The six-year-old died in the early hours of October 22, 2019, after going into cardiac arrest and collapsing at his school in Broken Hill, in far west NSW, the previous day.
School staff and paramedics were able to revive him and he was taken to Broken Hill Base Hospital, where it was agreed his condition was serious enough to require a medical transfer to a city facility.
A transfer team didn't arrive until just before midnight, and Austin collapsed as he was being prepared for the flight, an inquest into his death heard.
He was pronounced dead just after 2am.
"The evidence established there were significant flaws in the planning for the transfer, which led to unacceptable and avoidable delays," Ms Ryan said, handing down the inquest findings at Lidcombe Coroners Court on Thursday.
"Although everyone involved in Austin's retrieval had his best interests at heart, his transfer was afflicted with systemic deficiencies and flawed decision making.
"For many hours, there was simply no settled plan to transfer Austin anywhere."
Ms Ryan said she was unable to determine whether a speedier transfer to a city would have prevented his death.
"But there is no doubt that a more timely transfer had the potential to improve his chances of survival," she said.
"For (his parents), there can be little comfort in this conclusion. They will always ask themselves if their little boy might have lived had his transfer not taken so long.
"The long wait that afternoon and evening must have been harrowing."
Ms Ryan said the inquest was important for other people living in rural and remote parts of the state, "who deserve to have the earliest possible access to full hospital services like patients elsewhere in NSW".
"Inquests are an opportunity to examine whether they are getting the health services they need and deserve," she said.
"The evidence at this inquest established there was a lack of clarity as to which service had ownership of Austin's transfer, which together with sub-optimal decision-making, led to failure in communication and planning."
Ms Ryan said while there were unacceptable delays, Austin received appropriate care at his school and from staff at the hospital.
She made three recommendations, including the need for mutually agreed guidelines on transfers, covering operational and clinical processes, to be settled as soon as possible.
Six months ago, Ms Ryan found "serious and unacceptable" deficiencies in the treatment of teenager Alex Braes at Broken Hill hospital.
Mr Braes died of sepsis in 2017, after he was refused admission to a South Australian tertiary facility due to a policy preventing interstate transfers.
A NSW Health budget estimates hearing in September was told Mr Braes' death led to an agreement with SA Health and there were now 300 emergency transfers from Broken Hill to Adelaide each year.
Ms Ryan acknowledged the inquest into Austin's death was deeply painful for his family.
"I know they will always grieve for Austin and I hope in time that sorrow will lift, and they will find some peace."
