A 15-year-old girl went into cardiac arrest and died just hours after she was told by a GP she had an ear infection.
Rosie Umney, who had type 1 diabetes, was taken to a GP surgery by her mother because she was vomiting, hyperventilating and struggling to walk.
Dr Sadaf Mangi from the William Street Surgery in Herne Bay, Kent, failed to recognise Rosie was exhibiting the symptoms of potentially fatal ketoacidosis.
Instead of referring her to hospital, Dr Mangi sent Rosie home. She died later that night.
Rosie Umney, 15, died on July 2, 2018 after Dr Sadaf Mangi told her she only had an ear infection
An inquest heard how Rosie had been feeling seriously ill during the afternoon of July 2, 2018.
With her parents at work, her granddad Michael Umney was called to her school to take her home.
Later that evening Rosie was hyperventilating, had a terrible pain in her side, was sick and had reflux, which she had never experienced.
Although her mother Georgina Umney had booked a GP appointment for Rosie the following morning, they booked an emergency appointment.
They took her to the William Street Surgery, and had to assist her to into the car.
Once there, another woman who was waiting saw the condition Rosie was in, and suggested that the teenager see the doctor before her.
Rosie was examined by Dr Sadaf Mangi, and finding she had a heart rate of 140 beats per minute, said she was suffering from an ear infection and gave her a prescription for some medicine.
Mr Umney said: 'I was amazed because I was sure she was going to say to go to hospital.
'I said to Georgia I didn't feel happy about what Dr Mangi had diagnosed.'
Rosie with her mother Georgina Umney. She booked an emergency doctors appointment for her daughter but the GP incorrectly diagnosed Rosie
Diabetic ketoacidosis (DKA) is a dangerous build up of chemicals in the body if someone begins to run out of insulin.
Insulin is a hormone which the body uses to absorb sugar to be used for muscle energy, but people with diabetes often do not produce enough.
When they begin to run out, the body desperately starts to break down fat to obtain energy. This can called a build-up of chemicals called ketones which are released when fat is digested.
As ketones build up to cause DKA they can begin to cause frequent urination, vomiting, stomach pain, acidic-smelling breath, breathing problems, sleepiness and confusion.
If left untreated the patient can pass out or even die in extreme circumstances.
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