The tragic death of a six-year-old girl after she was transferred to a Brisbane hospital was "completely avoidable", her mother's lawyer says.
Lilli Sweet was taken to Nambour Hospital's emergency department in August 2013 but died two days later after being moved to Brisbane.
Before her death, the young girl suffered from a medical condition called hereditary spherocytosis, which makes a patient more susceptible to severe and life-threatening infections.
Her death was not immediately referred to the coroner but an inquest was held after an internal review conducted by the Royal Children's Hospital raised concerns about her treatment at Nambour.
In handing down his finding on Friday, Deputy State Coroner John Lock also noted Lilli was vaccinated according to a standard schedule but not on the basis she was an "at risk" patient following an operation to remove her spleen.
However, he ultimately found those additional immunisations would not have guarded against pneumococcal meningitis, the infection that led to her death.
There were also conflicting views within medical literature about the antibiotics treatment required after the surgery, given the removal of the spleen puts a person at a lifelong increased risk of severe bacterial infection, he found.
Notably, the coroner said a senior medical registrar at Nambour who saw Lilli when she became ill in August 2013 was told about her spleen condition and operation but decided not to do blood tests while she was in the emergency department.
"He was of the view that ... she had a viral illness," Coroner Lock said, noting the clinician didn't appear to consider an alternative cause for her deteriorating health.
This was despite a GP detailing to the hospital that Lilli was asplenic and prone to bacterial infection, and would likely require blood tests and a paediatric review, he said.
Peter Boyce, counsel for Lilli's mother Joanne, pointed to this as the "first failure" in Lilli's treatment.
"It is probably the most tragic event that I've ever been involved in, in the sense of something that was completely avoidable," he said.
"Poor old Joanne, she has to soldier on."
Despite referring to "missed opportunities" that could have prevented Lilli's death, Coroner Lock found no further recommendations were needed given safeguards had since been put into place.
"It may be of some little comfort to Lilli's family that so much has been advanced as a result of her tragic death," he said.
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