A mother whispered 'goodbye baby' as she watched her four-year-old daughter die in hospital when a doctor failed to administer the treatment she needed to save her life.
Mum Carly Wells's words were the last she would ever say to her daughter Freya as she was being sedated by medics.
An inquest heard that just 25 minutes later, Freya died from septic shock after a hospital registrar failed to administer intravenous antibiotics quickly enough.
Ms Wells took Freya to her GP twice before taking her to A&E because she had been ill for five days and wasn't getting any better.
She said in a statement: " I was very worried about Freya - it seemed her whole body moved when she took a breath, she would make a grunting noise and was wheezy.
"I took Freya to Kingston Hospital straight away, I was with her the entire time except for less than a minute when she was put to sleep at 5.40am - I don't think I even went to the toilet because I wanted to stay with my little girl the entire time.
"The doctor didn't seemed concerned - at no point until the end did they give the impression that there was something very serious with Freya. They didn't tell me what was wrong or do anything with urgency.
"After an X-ray of her chest a nurse spoke to me and said Freya had a chest infection so would be kept overnight.
"Another doctor, called Dr Ibrahim, came along as well, she didn't seem to think there was anything wrong with Freya either.
"I was worried because she was clearly unwell just to look at her. I remember Freya was given oral antibiotics in A&E and was sick again after taking the medication. My memory is a bit blurred after that - Freya was transferred to the children's ward."
Ms Wells tried to get her daughter to sleep but she was 'clearly scared and wanted hugs' after vomiting and having diarrhoea in her hospital bed.
She said: "Even when we were on the children's ward not a lot seemed to happen. Nothing made me panic until they said they would have to put Freya to sleep.
"As time passed Freya seemed to get worse. I felt helpless because my little girl was crying and asking me to make things better. The doctors didn't seem to be doing anything."
Ms Wells said the first time a doctor told her anything was wrong was when Freya was put to sleep to help her breathe.
She added: "There were lots of people everywhere - wires and tubes were attached to Freya, she was screaming, I had to hold her leg down because there were not enough people to do that.
"I remember kissing Freya saying 'goodbye baby'. I didn't know it was the last thing I would ever say to her.
"When I was told my little girl had died, it felt like my whole world had died as well."
The inquest heard that if septic shock is diagnosed immediately, there is a 95 per cent chance of survival, but the initial mortality rate of five per cent doubles each hour it is not detected and treated.
Dr Marilyn McDougall, a paediatric consultant who conducted an investigation into Freya's death, told the inquest that by the time doctors realised what was wrong her chances of survival were 'very, very slim'.
She said: "Freya was extremely tachycardic and in respiratory distress, which was in keeping with the diagnosis of septic shock. If this had been recognised earlier, her chances of survival would have been greatly improved."
The consultant told the inquest that registrar Dr Rosita Ibrahim failed to recognise the 'severity' of Freya's condition, saying she would have expected a 'more comprehensive assessment'.
However, she added that 'it was not obvious she was unwell', saying a 'thorough examination' is needed to establish a diagnosis of septic shock.
The criminal charges could be brought if West London coroner Dr Sean Cummings concludes unlawful killing, because the Crown Prosecution Service would be notified and could prosecute.
However, Dr Ibrahim's representative Shaheen Rahman, argued against a verdict of unlawful killing because her client noticed Freya had an infection.
She said: "It is absolutely clear that the approach throughout this inquest hasn't been founded on suspicion. Nobody has been asked if this was a gross negligence kind of case.
"This wasn't a case where there was a failure to see if the patient was unwell. It was appreciated there was an infection and appreciated it was pneumonia.
"Antibiotics were given, fluids, in fact extra fluids, were given."
The inquest continues.