Gracie Foster: 'Gross failures' a factor in girl's hospital death
A four-year-old girl "would have survived" had medical staff undertaken "basic" checks, an inquest found.
Gracie Foster died at Sheffield Children's Hospital in October 2015, hours after being discharged from Chesterfield Royal Hospital when a routine operation was cancelled.
Dr Robert Hunter, senior coroner for Derby and Derbyshire, said she "died of natural causes contributed to by neglect".
He recorded a narrative conclusion.
The inquest heard that Gracie, of Old Whittington, Derbyshire, was due to have her tonsils removed but fell sick on the ward and was sent home, believed to be suffering from a viral infection.
She was admitted to the Nightingale ward in Chesterfield at about 08:15 GMT on 21 October and appeared to be well at first, but when her mother Michelle Foster heard a "loud whinge" from the play room Gracie was taken to a bed.
After being given pre-operative medicine at about 10:30, Gracie vomited and a nurse found her temperature to 40.1C.
Her operation was cancelled and an anaesthetist who examined her said she was suffering from a "likely viral illness".
A consultant paediatrician made an "informal examination" of her tonsils to make sure she did not need antibiotics and no formal referral was made to the paediatric department, the inquest heard
Gracie was discharged and taken to her grandmother's home in Dronfield.
After she deteriorated she was taken to hospital in Sheffield, where she died from "Waterhouse-Friedrichsen syndrome as a complication of meningococcal septicaemia".
An independent panel of experts told the inquest had Gracie received full observation checks and been treated with antibiotics before 15:00, then "on the balance of probabilities" she would have survived.
Dr Hunter said there were "missed opportunities to asses Gracie and detect the underlying cause of her fever" before she was discharged.
"The seriousness of her condition was underestimated, went undiagnosed and therefore untreated," he said.
Dr Hunter also pointed to the lack of policy in place at the hospital to assess children who become unwell in hospital and have planned operations cancelled, which he described as "a system failure".
The inquest had heard another child at Gracie's school had been diagnosed with meningococcal disease weeks before her death, but Public Health England (PHE) only notifies hospitals when there is an outbreak of infectious illness instead of individual cases.
Dr Hunter said he would write to PHE to "express concerns" over the policy.
Carolle White, from Nelsons solicitors, said in a statement on behalf of Gracie's family that they "will never recover" from her death.
A spokesman for Chesterfield Royal Hospital NHS Foundation Trust said it was "truly sorry" over Gracie's death, and said it had already put in place new procedures "under our own initiative".