A coroner has found that a locum doctor should have sent a three-month-old baby to hospital when she was brought to him pale, lethargic and suffering from diarrhoea.
Skylah Vaimalu died suddenly at home in Porirua in 2007 despite being seen by three different doctors during a 10-day period.
Wellington coroner Ian Smith says the last of the doctors to see her should have arranged for her to be admitted to hospital.
He says the baby died from sudden unexpected death in infancy due to bronchopneumonia.
Mr Smith says the last doctor to see her, Dr Nguyen, now lives in Australia.
He says had Dr Nguyen still been practising in New Zealand he would have recommended he receive formal training in paediatric medicine.
Skylah Vaimalu's mother, Travilla Pupuke, told the inquest there was a lack of communication by the doctors involved in treating her daughter.