Dr Etta Campbell is urgently investigating the two deaths
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The death of a baby following treatment at a County Fermanagh hospital was "entirely preventable", Northern Ireland's chief medical officer has said.
Seventeen-month-old Lucy Crawford died at the Royal Victoria Hospital in Belfast in 2000 after being admitted with gastro-enteritis to the Erne Hospital in Enniskillen.
The cases of Lucy and nine-year-old Raychel Ferguson from Londonderry have been highlighted after recent inquests.
Both children died as a result of the incorrect administration of fluids to counteract dehydration.
Dr Etta Campbell said on Thursday that Raychel's death at Altnagelvin Hospital in Derry in June 2001 could have been prevented if the full circumstances of Lucy's death had been known sooner.
Dr Campbell was speaking for the first time after beginning an urgent investigation into the cases.
New medical procedures have since been put in place.
Dr Campbell has written to each health trust in Northern Ireland to ensure they are strictly adhering to the procedures.
She said Lucy's death was "entirely preventable".
"I think we learned that very early on, and certainly from the inquest, that has become very clear," she said.
"It is of paramount importance to the Health Service that it should never happen again."
The chief medical officer now accepts that there was a potentially fatal flaw in the system.
"On looking back at the issues, I think if we'd had an early inquest into Lucy's death, Raychel's death might not have happened. We have to recognise that," she said.
"What the coroner has now agreed is that he will draw to our attention very early on those deaths about which he has concern."
Raychel's parents, Marie and Ray Ferguson, are taking legal action.
Mr Ferguson said he was angry that the lessons of Lucy's death were not learned in time.
"If the doctors had known about it, Raychel would still be here," he said.
"Words can't explain it - you just feel empty all the time."
At an inquest in February, Belfast Coroner John Leckey ruled there were errors in the treatment given to Lucy Crawford.
Mr Leckey said errors at the Erne were compounded by poor medical record keeping and confusion among the hospital's nursing staff.