Seven-year-old Aishwarya was left in a waiting room for more than 90 minutes upon presenting at Perth Children's Hospital on Easter Saturday last year with a fever, despite her parents pleading with staff to escalate care.
Deputy state coroner Sarah Linton has been told Aishwarya stood little chance of surviving by the time staff realised how serious her condition was.
Ms Linton has heard there was intense demand on emergency department staff, including a junior waiting room nurse who was unable to monitor Aishwarya because she was repeatedly called away on other duties.
That nurse did not consider sepsis, despite having observed Aishwarya to have an elevated heart rate, respiratory rate and temperature, and to be floppy and grunting in pain.
At the conclusion of witness evidence on Friday, the coroner outlined her preliminary thoughts.
Ms Linton said the evidence suggested the hospital had not been appropriately staffed to handle a surge in presentations on the night of Aishwarya's death.
In the context of workload pressures, it was clear staff had missed opportunities to recognise the severity of Aishwarya's condition, she said.
"There's moments along the way where things could have been escalated, certainly in the earlier stages," Ms Linton said.
"The problem is a little girl died, and we all have to reflect upon that and think about how can we make sure this won't happen again."
Ms Linton paid tribute to the "grace and dignity" of Aishwarya's father Aswath Chavittupara and mother Prasitha Sasidharan, who have attended each day of the inquest.
The couple has claimed hospital staff were rude and dismissive of their concerns.
"It must have been excruciating ... knowing in their hearts how unwell she was," the coroner said.
"They were trying to follow the rules but at the same time getting more and more desperate."
Ms Linton acknowledged the COVID-19 pandemic had created "unprecedented" pressures and the hospital had made significant changes, including hiring more staff.
But she questioned whether the changes could have been made earlier given nurses had raised concerns months prior to Aishwarya's death.
Adverse findings could potentially be made against individual staff, she added.
Tim Hammond, acting for Aishwarya's family, submitted there had been at least three crucial missed opportunities in short succession.
"The great tragedy is ... those missed opportunities were preventable," he said.
"Had just one of these opportunities not been missed, there is a chance ... she would have actually defeated this illness."
Mr Hammond read a statement by Aishwarya's parents, who asked the coroner to honour the memory of the happy little girl who had dreamed of being a teacher.
"Why should our health system change only after losing an innocent little life?," they wrote.
"We will never forgive our health system and the people associated with it."
Belinda Burke, representing the nursing union, submitted that no adverse findings should be made against the nurses given their workload pressures.
Child and Adolescent Health Service executive director Simon Wood earlier conceded it would be "disingenuous" to suggest the hospital had been sufficiently staffed on the night Aishwarya died.
He acknowledged the hospital was still working to repair relationships with frontline staff and to fill vacancies, having almost doubled its nursing numbers.
Ms Linton will deliver her findings at a later date.
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