Hineihana Sosefina Mausii was twice sent home from hospital with a suspected viral infection, only to die just hours later from leukaemia on October 29, 2013.
After a coronial inquiry in the Dunedin District Court this week into her death, the 2-year-old's mother, Tracey Elvins, spoke about her battle for justice.
"She was a beautiful child and I've got so many loving memories of her," she said.
"But then it always comes back to what didn't happen for her at the hospital."
Despite coming to the end of the process, Ms Elvins said she was not expecting closure.
"People will say `it gets easier'. It doesn't get easier, you just get numb to it," she said.
"I miss her so much - you can't express it."
A consultant who failed to examine the toddler in the emergency department and a nurse who spoke to Ms Elvins through Healthline were found to have breached the professional code of conduct, while another doctor was also censured.
Yesterday Southern District Health Board chief medical officer Dr Nigel Millar apologised to the family.
"Failure to recognise the severity of Hineihana's illness led to a series of events that would have been deeply distressing to the whanau and would have increased their pain, suffering and grief that they undoubtedly experienced. We remain truly sorry for this."
Dr Millar said it was imperative doctors listened to parents.
"When parents bring their child back to ED they bring them back because they're concerned and it's really important in those circumstances ... to go back and start from the beginning and not make assumptions or continuation of what was previously thought at the first attendance. After all, the parents know their child best," he said.
"We always have a risk of what we call `cognitive bias' ... People start to form an opinion before they have full information, based on things they have heard or been told or read - it affects all of us. As clinicians, we've got to try and avoid being caught up in that."
The inquiry before coroner Brigitte Windley previously heard Hineihana had been discharged despite a junior doctor and nurses having worries for her wellbeing.
Dr Millar said the health board had worked hard to eradicate a culture where staff felt like they could not challenge decisions.
"I can see in this there were people who felt concerned, who maybe didn't feel able to speak up and that makes me feel uncomfortable," he said.
"We need to have a system that acknowledges anyone can make an error."
Ms Windley reserved her findings and Ms Elvins said she looked forward to hearing her recommendations to avoid future tragedies.
She described Hineihana as her "miracle baby".
"I didn't think I was going to have children," she said after yesterday's hearing.
"She was an amazing little girl ... She was so caring."
