A baby boy died after doctors dismissed his meningococcal meningitis symptoms as teething.
The parents of seven-month-old Malakai Paraone took their boy to two hospitals and doctor's surgery after he developed a fever and rash.
The little lad was in pain but doctors diagnosed a pulled elbow and teething problems and sent him home with paracetamol, reports 7News .
An inquest into Malakai's death at a hospital in Perth, Australia, was held today.
It was found that doctors failed to recognise his symptoms when he was sent home from Midland Hospital and Princess Margaret Hospital for Children in August 2016.
Dr William Holloway from Princess Margaret Hospital told the inquest that the lack of consistency in Malakai's treatment at the different sites could be a contributory factor in his life "falling through the cracks."
The lawyer assisting the coroner also conceded this point.
The coroner heard that Malakai's symptoms were finally recognised by the family's GP and a third visit to the hospital.
He was hastily returned to Princess Margaret Hospital where he was put on life support.
But by then, it was too late, and the little lad died three days after he'd first been brought to hospital.
The child's family is calling for radical changes to be made to Australia's medical system.
Dr Holloway told the inquest that the system could be reformed to ensure a child's treatment was conducted by the same doctor or hospital every time so that treatment remained consistent.
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