A coroner has questioned why it took so long to transfer an unwell six-year-old girl from Royal Cornwall Hospital to the Children's Hospital in Bristol in July 2017.
On 25 July 2017, Coco Rose Bradford was taken to A&E at Treliske after being sick and experiencing diarrhoea.
She was sent home with a diagnosis of gastroenteritis and emergency department staff said she could be given fluids and recover there.
Coco returned on the 26 July and was admitted to the paediatric ward, where her condition significantly deteriorated. She developed haemolytic uraemic syndrome (HUS) which involves damage to blood vessels. This can lead to life-threatening kidney failure.
The inquest, which begun on 29 November, heard there were persistent problems with record keeping, medical reviews and test results. In turn, this prevented an accurate picture of Coco's condition from being put together.
Coco became extremely unwell overnight from 27 to 28 July.
Today (December 2), the fourth day of the inquest, the consultant who was on-call overnight was called to speak. Dr Sharma Goyal became a consultant at Treliske in 2017.
Dr Goyal told coroner Andrew Cox she had an 'unusually long handover' and found out Coco had not had a medical review since 10:45am that morning.
When she visited Coco, the consultant found her heart rate had been raised for more than 24 hours and had a temperature for more than 12 hours. Dr Goyal said she was 'very concerned' and decided to speak to the microbiologist.
The inquest heard the microbiologist advised antibiotics should be administered but there was a risk this could precipitate HUS. Dr Goyal explained this was the reason she decided against giving Coco antibiotics.
The coroner questioned this by adding that when Coco did eventually get transferred to the Intensive Care Unit, she was given antibiotics.
"On the face of it, this is a contradiction"
The inquest heard at around 1am on 28 July, Coco got a confirmed diagnosis of HUS. The coroner said: "She's not getting better, she's getting worse. Did you now think she needs to go to the ICU and then transfer to Bristol?
"From 11pm on 27 July, it seems clear that she needed to be moved earlier."
Dr Goyal replied: "In my view, at midnight, she did not need to go to the ICU or go to Bristol."
At around 5.30pm on 28 July, Coco left Treliske and begun the transfer over to the Bristol Royal Hospital for Children where she was treated on paediatric Intensive Care Unit. Three days later, on 31 July, she died.
The coroner asked Dr Goyal what would help medical staff in the future when prescribing antibiotics to a child with developing HUS and at risk of sepsis.
Dr Goyal said: "It would be very helpful to have guidance on managing fluids when a patient has dehydration."
She said there has been changes to staffing at Treliske since 2017. There are now two consultants on-call overnight, one for the neonatal unit and one for paediatrics.
The inquest is due to conclude on 10 December.