A coroner has found that a severely sick Porirua baby was sent home three times by three different doctors before she died at home.
Three-month-old Skylah Vaimalu died on September 1, 2007, after developing flu-like symptoms in August following her immunisations, as well as a high-pitched cough and diarrhoea.
She was initially diagnosed with bronchiolitis and sent home from the Waitangirua Health Centre.
However later that afternoon her mother took her to the Emergency Department at Kenepuru Hosital as she developed a high temperature and was bleeding from the nose.
She was again diagnosed as having bronchiolitis.
Skylah's health deteriorated in the following days and was sent back home a third time - she died two days later.
According to the coroner's report, Skylah's mother, Travilla Pupuke, felt her concerns for her daughter's health were being ignored.
"... Ms Pupuke believes that a different outcome may have occurred if Skylah had been admitted to hospital for observation as infants can deteriorate fast. She was also critical about the lack of the information that she had been provided with by the doctors regarding the medication."
Forensic perinatal pathologist Dr Jane Zuccollo carried out the post-mortem on Skylah and diagnosed "sudden unexpected death in infancy, moderate bronchopneumonia, pale soft live, and a question mark of maybe an underlying metabolic abnormality".
Paediatrician Dr Nikki Blair said baby Skylah dropped from 7kgs to 5.5kg in the 10 days before she died, and was severely dehydrated.
In his findings, coroner Ian Roderick Smith said Skylah should have been admitted to hospital at the third visit.
Mr Smith said he would have recommended the final doctor who saw Skylah, Dr Huu Hoai Nam Nguyen, receive more formal training in paediatric medicine, however he has since moved to Australia.
Skylah's family have also relocated to Australia.