A coroner told an inquest a Melbourne hospital could have prevented the death of a two-year-old boy, who was assessed by five doctors in as many days.
Lachlan Black died of septicaemia at the Monash Hospital emergency department in 2014.
He was diagnosed too late after his parents’ concerns were ignored.
Medical professionals only prescribed antibiotics nine hours after he was admitted.
During Wednesday’s inquest Coroner Rosemary Carlin found there were a number of missed opportunities to diagnose the young patient.
"It is likely his death would have been prevented had he received appropriate care from the outset," Coroner Carlin said at the inquest into the child's death.
Lachlan’s mother Angela said medical staff should listen to parents about their child’s health.
“All too often parents are treated as not an expert ... they don't know anything… I just felt we were shut out of that process.
"It is likely his death would have been prevented had he received appropriate care from the outset," she said.
Her husband Tim added: “Doctors need to keep in mind that in their profession when they make mistakes, those mistakes can’t be undone.”
Medical negligence lawyer Kathryn Booth, of Maurice Blackburn, said the inquest’s findings confirmed “Lachlans death was preventable and that he did not receive reasonable care".
“This should be a very important learning case for the medical profession and Monash Health should adjust their protocols,” she told 7 News.
The coroner is recommending changes to the way Monash Health managed patients, particularly those who return to emergency within three days of being discharged.
Monash Health said it implemented a number of changes since the tragedy, particularly in relation to those patients who return to the hospital within three days of being discharged.
The Black family has begun legal action against the hospital, with the case to be heard in the Victorian Supreme Court next year.
The boy’s mother said she hoped that making the hospital accountable will save lives.
“We can't get Lachlan back, but all we can do is fight as hard as we can and push as hard as we can for change so that this doesn't happen again to someone else, because we know how painful that is,” Ms Black said.