There were errors in the treatment given to a County Fermanagh toddler who died four years ago, the Belfast coroner has ruled.
Lucy Crawford was admitted to the Erne Hospital in April 2000
Seventeen-month-old Lucy Crawford died in 2000 after being admitted to the Erne Hospital in Enniskillen, suffering from gastro-enteritis.
The baby, from Letterbreen, was treated for dehydration but later died after being transferred to the Royal Victoria Hospital in Belfast.
Belfast Coroner John Leckey said on Thursday that the errors at the Erne were compounded by poor medical record keeping and confusion among the hospital's nursing staff.
Mr Leckey said that he would refer the case's papers to the General Medical Council.
The trust which governs the Erne said in a statement that the case was "a tragedy" and that new procedures were now in place.
The inquest earlier heard from another expert witness who claimed the child's care was "sub-standard".
Consultant paediatrician Dr John Jenkins, said there was "confusion between staff".
Dr Jenkins said there was inadequate documentation and record keeping on how much and what type of fluid she was given for dehydration.
Meanwhile, the consultant in charge of baby Lucy, declined to take the witness stand at the inquest.
In a statement read by the Crawford family's solicitor, they said they were astonished that Dr Jarlath O'Donaghue had refused to come forward to give evidence and answer questions.
"Mr and Mrs Crawford's pain at the loss of their daughter is compounded by the knowledge that her death was unnecessary and could so easily have been avoided," the statement said.
On Wednesday, an anaesthetist at the hospital said he agreed with evidence given that the level of care given to Lucy was not up to standard.
Expert witness Dr Dewi Evans, a consultant paediatrician from Swansea, also told the inquest that the wrong type and amount of fluid had been given to her.
He said this caused the swelling of her brain which led to her death.