A four-year-old girl admitted to hospital with a 95 per cent chance of survival died after being treated by a doctor who was "painfully" out of her depth, a British inquest has been told.
Freya Wells was vomiting and had trouble breathing when she went to the Kingston Hospital in 2012
She was given the wrong medication by Dr Rosita Ibrahim, who ignored constant advice to change her treatment and eventually called the pediatric consultant too late.
Junior staff repeatedly asked Dr Ibrahim to administer antibiotics intravenously when Freya could not keep down the orally administered medication because she was vomiting, the MailOnline reports.
Coroner Dr Sean Cummings said: "It is painfully clear to me that Dr Ibrahim was out of her depth."
The doctor's licence has been suspended pending a full investigation.
"There were identifiable failings in the care of Freya and a notable failure to recognise the basic fact that she was very seriously ill in septic shock and needed aggressive and vigorous treatment," the coroner said.
Freya was taken to hospital November 21, 2012 by her mother Carly Wells. Dr Ibrahim thought she was suffering from pneumonia, the MailOnline reports.
Dr Ibrahim dismissed concerns from a junior doctor who suggested that a consultant should examine Freya as well.
Freya was eventually given intravenous antibiotics but her condition had deteriorated, she went into cardiac arrest and died.
Dr Cummings said: "She wasn’t treated competently and appropriately and she died in shocking and harrowing circumstances."
Consultant Titilola Ayeni said: "There was no urgency, no recognition that the situation was an emergency - it is what I call a meandering discussion.
"She had been the most ill patient on the ward so she should have been in the High Dependency Unit so we could have observed her more closely."
After the ruling, Freya's family said they were considering taking legal action against the hospital where she was treated.