A Melbourne hospital failed to properly care for an 18-month-old girl who died days after she was admitted, a coroner has found.
Audrey Ebbage died in December 2014, four days after she was admitted to the Northern Hospital in Epping for suspected croup.
The tot's parents raised concerns about Audrey's management at the facility and said they felt concerned about her throughout her admission and "never felt heard".
They requested a coronial inquiry to consider whether earlier diagnosis of a heart condition may have prevented their baby's death.
In her finding released this week, Coroner Jacqui Hawkins found Audrey died of an undiagnosed heart condition and she would have needed a heart transplant to survive.
Describing the treatment as "sub-optimal", Ms Hawkins said young doctors cared for Audrey to the best of their ability but were "inadequately trained and supervised".
Angela and Matthew Ebbage took their daughter to the Northern Hospital's emergency department about 6pm on December 11, 2014.
She was breathing noisily and rapidly and was diagnosed by doctors at the hospital as having croup or the first presentation of asthma.
A plan for a chest x-ray was cancelled and Audrey was moved up to the ward.
On December 13, a worried Dr Angela Ebbage raised concerns that Audrey's condition was deteriorating.
At 6am on December 14 Dr Ebbage activated the emergency alarm when Audrey became limp and was struggling to breathe.
She was pumped with adrenaline and rushed to the Royal Children's Hospital where she died the next day.
The inquest heard many changes had been enacted at the hospital following Audrey's death and many of the staff involved were no longer working at the hospital.
Her parents hope the inquest will prevent future deaths.
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