A seven-year-old girl died three days after being discharged from hospital with blue lips – a sign of organ failure.
Simran Dhesi died from heart and liver failure after A & E doctors at Sandwell General Hospital, West Midlands, said she was 'fine' following admission for vomiting and abdominal pain.
Simran was rushed to another hospital two days later and died of cardiac failure on the operating table as doctors tried to drain fluid from her heart on September 10, 2010.
Simran's mother Tarlochan Dhesi, 34, told the inquest Dr Raka Banerjee dismissed her concerns about her daughter's blue lips in the casualty department - and said she was cold.
In a statement read out at the inquest, she said: "A lady doctor (at Sandwell General Hospital) checked Simran.
"She tested her urine, she took blood from Simran's finger and she said Simran was okay.
"I asked the lady doctor to check Simran's stomach. She moved her stomach this way and that way and said it was fine.
"I asked her why her stomach was so hard. She said it was fine. I asked about Simran's lips being blue and she said it was because it was cold."
A statement from Dr Banerjee read: "I know my notes are incomplete and the reason for this is I must have been interrupted.
"Unfortunately the A&E card must have filed before I could complete it. I'm sorry for this.
"I was certain I did not have concern for Simran's well-being otherwise I would have not discharged her.
"I would certainly have been aware if there had been an enlarged liver and I would have requested a paediatric opinion."
Returning a narrative verdict, Black Country Coroner Robin Balmain said: "I have borne in mind these are natural causes but natural causes would not reflect this situation.
"Simran's death was due to a rare complications in a congenital heart defect which had been corrected.
"The opportunity to treat and prevent the causes did not arise in time to prevent death."
Simran's parents Jatinder and Tarlochan said they were considering taking legal action against the hospital she was discharged from.
In a statement they said: 'It has taken over three years for this inquest to take place.
"Even now, one of the key doctors who saw Simran first, did not give evidence, which was disappointing.
"Simran was a happy, playful little girl who had a beautiful smile bringing happiness to us and everyone in her life.
"She leaves a loving extended family whose lives have been shattered as a result of her tragic death and we can now only take comfort from happy memories of her short life.
"We believe the coroner's inquiry has shown Simran was a very sick child who needed urgent specialist medical attention which sadly she never received."