An NHS hospital apologised tonight for failing to provide an adequate standard of care for a schoolgirl who starved to death after all her milk teeth were extracted.
An inquest into the death of Sophie Waller, an eight-year-old with an extreme phobia of dental treatment, found she had an undiagnosed psychological syndrome.
Dr Emma Carlyon, the coroner for Cornwall, said the severity of her condition was not realised and this "prevented her from receiving the medical support that could have prevented her death".
Dr Ellen Wilkinson, the medical director of Royal Cornwall Hospital NHS trust, apologised to Sophie's family. She said: "There were shortcomings in the communication between the health organisation and Sophie's parents."
Sophie Waller died in December 2005 after refusing to eat or drink following an operation to remove all her milk teeth at the Royal Cornwall hospital in Truro in November.
The inquest heard on its final day today that her hospital aftercare was not organised or managed properly.
The eight-year-old was referred to the hospital by the family's GP after cracking a tooth on a boiled sweet and starving herself for three days because she was terrified of a visit to the dentist.
During the operation doctors at the hospital decided to remove all her milk teeth to avoid later problems. Her mother said the decision had left her daughter "devastated" and she again refused to eat and drink.
The inquest at Truro city hall heard that Sophie had been sent home to be cared for by a community psychologist and her GP, but that the eight-year-old was not seen face-to-face by any medical staff after her discharge.
Her medical notes were also sent to the wrong GP and no GP was directly contacted by the hospital regarding her case. There was confusion over how ill the girl was because her GP did not receive full details of her condition from the hospital.
The inquest heard that Sophie was so emaciated in the days before her death that her hair was falling out and her spine was clearly visible through her skin.
Dr Charles Holme, a consultant paediatrician, said Sophie's situation was so unusual that a GP should have been contacted directly and briefed on the case when she was discharged. A care plan should have been set up to weigh and check her regularly, he said.
"It would have been easy to have just picked up the phone and spoken to a GP. That was not done," said Holme.
"The GP should have been spoken to on discharge. It seemed to me to be an unsatisfactory way of doing things."
Holme told the inquest that a full psychological assessment of Waller should have been carried out before the operation to remove all her milk teeth, which he described as "a very major procedure for a small child".
Dr Arnon Bentovim, a consultant child psychiatrist, told the inquest that doctors had failed to organise a proper care plan for the child. "There was a failure to ensure that her ongoing medical care was fully managed and planned," he said.
"The concern about her that was shown on the ward was not reflected in the day-to-day care plan in the community.
"There needed to be a joint physical and psychological follow-up. It was optimistic to believe that the initial positive response was necessarily going to mean that this child would make a reasonable recovery," he said.
Bentovim said an opportunity to save Sophie was missed when her mother, Janet, contacted the hospital four days before her death and asked for her to be readmitted but was referred back to the community psychologist.
"At the point when the parents phoned the ward, and were clearly anxious enough to do so, had that anxiety been picked up then there would have been an opportunity for the death to be prevented," he said.
Following the operation, Sophie had been kept on a drip before being formally discharged from the hospital. She died at home 11 days later from acute kidney failure caused by starvation and dehydration.
