A fatal accident inquiry has found that one of two toddlers who died at the Royal Hospital for Children (RHC) in Glasgow could have survived if she had not been discharged.
Cailyn Newlands, who was just shy of her second birthday, died on December 6, 2016, in the emergency department at 8.42pm.
Her death came less than eight hours after that of 22-month-old Sonny Campbell.
READ MORE: 'Absolutely failed': Council sued over 'horrific' primary school carbon monoxide leak
Both toddlers were discharged from hospital before their deaths, a FAI at Glasgow Sheriff Court was told.
Sheriff Brian Cameron, who headed the inquiry at Glasgow Sheriff Court, said a "reasonable precaution" that might have prevented Cailyn's death would have been keeping her in a specialist observation unit.
However, he made no recommendations because the deaths were not predictable according to independent reports.
A miscommunication among doctors seems to have occurred.
Cailyn's family received an apology from NHS Greater Glasgow and Clyde for the miscommunication and their loss.
Sonny Campbell, a twin from Carntyne, Glasgow, had been admitted to RHC on December 5.
This was after a GP at Lightburn Medical Centre, following a four-day period of vomiting, advised his mother, Amy Reilly, to take him to the hospital.
The GP's examination on December 2 showed Sonny was "pale and irritable" and suspected he had gastritis and a respiratory tract infection (RTI).
The GP had also forewarned Ms Reilly that his twin could possibly be infected too.
At RHC, Sonny was triaged as Category 4 by Dr Aoife Ryan, a paediatrician, but was discharged without a consultant's examination.
Ms Reilly returned from running errands on the next day and noticed Sonny was "pale and yellow" and "taking short intakes of breath".
Isobel Reilly, Sonny's grandmother, began administering CPR.
An ambulance was called and they arrived at the hospital by 12.15pm.
Paramedics described Sonny as "unresponsive", with "poor respiratory effort" while his heart rate had dropped to 39 beats per minute despite chest compressions and an oxygen mask.
He was taken to the resuscitation unit but was described as having "blue lips."
Despite being intubated, no pulse was found, and he was pronounced dead 38 minutes later.
READ MORE: 'I'm at my wit's end': Resident slams council for failing to fix flat water problem
The post-mortem examination found bronchial pneumonia and streptococcus G, with the cause of death being acute haemorrhagic leukoencephalitis.
The court heard that the condition is "very rare and usually fatal."
A significant clinical incident review “found no fault in the care provided to Sonny”, and a separate review deemed that Cailyn’s death “was not foreseeable or easily preventable”.
Cailyn, from Renfrew, had been taken to hospital on December 2 with cold-like symptoms.
Her mother, Dawn Anderson, reported she had been "sleepy and lethargic", and she was admitted on a total of four occasions.
She was discharged from the RHC on December 2 after being noted as "bright and active".
However, her condition did not change and she was taken back to RHC by her parents on December 5.
In the car, she was sick, described as "dark green" vomit, and the family returned to be put in triage 5 before being discharged.
On December 6, Cailyn’s parents brought her back to RHC at about 6.34pm as she had vomited and developed a rash.
READ MORE: 'Careless' driver, 73, failed to see recovery vehicle and crashed
She was assessed as being Category 1.
Her recent history – including being readmitted twice on December 5 and again on December 2 – was shared with medics, and the child was described as "pale and placid" with "mottled skin on her legs and arms" and suffering "cardiovascular deterioration," the court heard.
Cailyn was given resuscitation for 40 minutes, but she died at 8.42pm.
The cause of death was given as Streptococcus pneumonia and severe necrotising bronchial pneumonia.
Share