A CORONER has found the death of a six-year-old girl could have been prevented if Nambour Hospital took action earlier.
The Coroner handed down findings this morning following an inquest into the death of Sunshine Coast girl Lilli Sweet.
In August 2013 she was taken to Nambour Hospital's emergency department when she became ill.
Deputy Queensland Coroner John Lock today found no one seriously considered Lilli was at risk of developing overwhelming sepsis from a bacterial infection.
Lilli was an asplenic child who was at risk of developing overwhelming sepsis, he said.
Mr Lock also said Lilli was not tested for a bacterial infection in the initial stages of being admitted to hospital.
"When blood tests were ordered the results showed the presence of or likely development overwhelming sepsis but these results were not acted upon until it was too late," he said.
"There were a number of individual judgment errors made that were compounded by systemic resource issues, which contributed to poor decisions."
As her condition deteriorated, Lilli became unresponsive, required emergency resuscitation and was transferred to the Royal Children's Hospital in Brisbane, where she died.
Lawyer Peter Boyce, who represented the Sweet family, including Lilli's mum Joanne, spoke outside court this morning after the findings were delivered and said the system failed the six-year-old girl.
"In the judgment the coroner has been very clear in making sure that there's lots of instances where it's not hindsight, it's failure; a complete failure," he said.
"There is no doubt Lilli should be still here with her brother and her mother and that's the most tragic thing out of this whole event. It was completely avoidable."
He said even though Nambour Hospital had conducted a root cause analysis following Lilli's death, the hospital's emergency department had still failed her.
"It is probably the most tragic event that I think I've ever been involved in, in the sense that something was completely avoidable."
Mr Boyce represented Lilli's mother Joanne and her twin brother Bailey during four days of the Coronial inquiry held in Maroochydore Magistrates Court last year.
Evidence during the inquiry reinforced two critical opportunities were missed to save her life.
Action at either point would almost certainly have averted tragedy.
The family's GP had sent Lilli to Nambour Hospital on August 25, 2013, a Sunday, because it was where she should have been able to quickly have blood tests done to determine if the cause of headache and neck pain she was suffering was a consequence of the infection to which she was susceptible due to a hereditary condition and the subsequent removal of her spleen to help manage it.
However, blood tests were not taken until 9.11pm and even though results before midnight showed a white cell count of 46,500 - well above the 10,000 normal range - the antibiotics that could have saved her were not administered until 9am the next morning.
An hour later, before they could have effect, she had passed the point of no return.
Lilli had a seizure, went into a coma and was flown to Brisbane's Royal Children's Hospital where she died the next day in her mother's arms shortly after her life support was removed.