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By Lucy Marks

An 11-year-old girl should not have died from septicaemia and a hospital could have prevented it had it given her appropriate treatment, the Northern Territory coroner has said. Gabby Wanambi from Nhulunbuy went to Gove Hospital in Arnhem Land for a rolled ankle in May 2014. A nurse contacted on-call doctor Geoffrey Harper because Gabby displayed signs of infection, but he did not come in, instead prescribing antibiotics and sending her home. Gabby returned to the hospital the following day in a deteriorating condition, and died of septicaemia with multiple organ failure.

Dr Didier Palmer, head of emergency medicine at the Royal Darwin Hospital, said based on the girl's presenting symptoms, including a heightened heart and respiratory rate, Dr Harper should have gone in to the hospital.

"It was that action of not going into the hospital that determined the outcome of this case," counsel assisting the coroner Kelvin Currie said, adding Dr Harper "made a very, very poor judgement".

Coroner Greg Cavanagh said "at the end of the day, this was a preventable death".

Dr Marco Briceno, who was working at Gove Hospital, said resources were "very thinly spread" at the time, and the hospital would have on-call doctors after 4:00pm, meaning many emergency room patients were not seen by a doctor.

"It would appear that after four o'clock your hospital would be a pretend hospital, it was a clinic," Mr Cavanagh said.

"This girl shouldn't have died the way she did, and it is evident that the ... appropriate treatment of sepsis at the time [would have prevented it]."

Gabby's Aunty Wendy Yunupingu spoke outside court on behalf of the family, saying they hoped the inquest would prevent a similar tragedy happening to someone else's child.

"For the next time, if any other kid gets sick, they can straight away be seen by a doctor and straight away be admitted to the hospital," Ms Yunupingu said.

"It's sad for us that we've lost our loving one, she was the sweetest girl, in her heart."

Second sepsis death at same hospital in five months

Five months before Gabby died, 21-year-old Sarah Hampel also died at Gove Hospital from septicaemia.

Mr Cavanagh also presided over the inquest into her death.

In a report shown to the coroner, the NT Health Department apologised for the deaths.

"I accept completely your remorse," Mr Cavanagh said.

"What is concerning to me is that exactly the same kind of explicit, profound apologies have been made several months before, after Sarah Hampel's death.

"I don't want to sit through another [inquest of this kind] ... I only have to think of my own kids and how angry I'd be."

He said there was only one reason the nurse called Dr Harper about Gabby's case "and that was for him to come in".

The hospital made changes after Ms Hampel's death, the inquest heard, but they did not go far enough to prevent Gabby's death.

"There needed to be essentially a clinical redesign, it wasn't about protocols because we'd done that and it hadn't worked," Dr Palmer said.

Changes since Gabby's death include a dedicated triage nurse, early warning signs of sepsis for paediatrics was developed and every patient who went to the emergency department is seen by a doctor.

"In terms of the practice of medicine which deals with life, it's just so important mistakes are learnt from," Mr Cavanagh said.

He has retired to consider his findings.