A 12-year-old girl would have survived if an ambulance had not taken an hour to get to her, a coroner has said.
Ffion Jones from Cardiff was taken to Rumney Primary Care Centre on 7 December 2016 as she been vomiting and appeared lethargic.
When she deteriorated further a GP called for an ambulance and requested an eight-minute response.
But by the time paramedics arrived an hour later she had gone into cardiac arrest and died later in hospital.
The inquest in Pontypridd reached a narrative conclusion and heard Ffion hadAddison’s disease, a rare condition where the adrenal glands in the kidneys stop functioning.
GP Nicola Leeson, who assessed Ffion, said she had recently received training in requesting ambulances to GP surgeries and had been given a specialist number.
She said she made the first call at 14:24 GMT but was told she needed to dial 999.
She said she was “very disappointed” but the operator said she would arrange an ambulance quickly.
The inquest heard Ffion briefly improved before collapsing and Dr Leeson put out a cardiac arrest call and other staff came to help her.
Dr Leeson said: “Just as we were applying the oxygen another receptionist appeared to say that I had to go and confirm it was a real cardiac arrest before the ambulance service would send an ambulance.
“I was obviously slightly distracted by the information I had just been given and was rendered speechless for a few seconds.”
The ambulance arrived at 15:30 GMT and took Ffion to the University Hospital of Wales.
She was pronounced dead the following afternoon after tests failed to detect brain activity.
Assistant coroner David Regan said: “The call was not escalated to the clinical desk as it should have been.”
He added if it had been escalated “it is likely she would have survived”.
He said he would make a prevention of future deaths report to the Welsh Ambulance Service NHS Trust.
‘Pillar of our family’
Nia Gowman, representing the ambulance service, said it was accepted there was a “missed opportunity” to escalate the GP’s call.
But she added: “In so far as Dr Leeson’s call is concerned, it is not accepted that had the call been appropriately escalated this would have led to Ffion not passing away.”
In a statement, Jason Killens, chief executive of the Welsh Ambulance Service said: “We would like to extend our sincere condolences to Mr and Mrs Jones and their family at this very sad and difficult time…
“We are deeply saddened, as our service exists to respond to the needs of the people of Wales.”
He said the service had carried out a joint investigation with Cardiff and Vale University Health Board and identified a series of improvements which would be implemented.
Speaking after the conclusion, Ffion’s father Anthony Jones thanked the coroner for a “thorough investigation” and said the family “entirely accept” his conclusions.
“Ffion was a generous, funny and bubbly little girl and was a pillar of our family,” he said.
“We hope that important lessons have been learnt and that no family has to suffer as a result of system failures.”