A two-year-old girl died from "neglect" after the "gross failure" of doctors who did not diagnose sepsis, a coroner has ruled.
Marcie Tadman was being treated for pneumonia at the Royal United Hospital in Bath when she suffered a fatal cardiac arrest on the morning of December 5, 2017.
She had been seen by seven doctors who were treating the pneumonia as the main cause of the toddler's illness and had not considered sepsis.
Senior coroner for the Avon area Maria Voisin listed a range of failings by the hospital and recorded a conclusion Marcie died from natural causes contributed to by neglect.
Expert Dr Nelly Ninis told the inquest at Avon Coroner's Court that systemic failures on the children's ward led to Marcie's death.
She said Marcie would not have died had staff followed their own guidelines, as well as those from the National Institute for Health and Care Excellence, to transfer her to a paediatric intensive care unit.
Marcie's father James Tadman had taken her to the hospital's emergency department the previous day because she had a cough, a high temperature and had been vomiting but the sepsis screening tool was not completed.
Three days before her death, Marcie had been seen by an out of hours GP who had diagnosed a viral infection and told her father to give her Calpol.
During the week-long inquest, doctors told Ms Voisin there was not an "ingrained" culture to test for sepsis on the children's ward.
A post-mortem examination found Marcie, who lived in Bath with her family, had died from a Group A Streptococcus infection with secondary pneumonia.
Trust medical director Dr Bernie Marden apologised to Marcie's family.