A mother has responded to coronial findings that her 12-year-old daughter's death was preventable.
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Former Oxley College student Angelique Burton-Ho died on August 11, 2015 at Sydney Children's Hospital in Randwick from cardio-respiratory failure.
A coronial inquest focused on the circumstances surrounding her death and the care she received at Bowral Hospital prior to her emergency admission to Sydney Children's Hospital.
According to the inquest findings released on November 23, Angelique's rapid deterioration was not recognised in a timely manner.
The 12-year-old had severe aspirational pneumonia against a background of significant congenital structural challenges.
Angelique's mother Armanda Ho said she was devastated that more had not been done to prevent her daughter's death.
"There were a number of missed opportunities where things could have been done differently," Ms Ho said.
"Imagine finding out that your child's death could have been prevented.
"Angelique's father and I are completely devastated to discover that had her case been handled differently, at numerous moments, this tragedy could have been prevented."
Ms Ho said it was a good thing that "such a detailed investigation has been carried out and the findings brought to light".
"The findings have not made her death any easier, however I hope this inquest has served to prevent such an outcome from happening again.
"I also hope that parents will feel empowered to express their concerns and escalate their case should they feel the need to. I would hate to have this happen to another child and their family.
"I am truly blessed to have such wonderful friends that have supported me since the day Angelique died and through this inquiry. My heart goes out to the students and teachers at Oxley that knew and loved her. I know how much her death has affected her friends and parents."
The court took evidence over four days from September 24 to 28 at the NSW State Coroners Court of NSW in Glebe and heard final oral submissions from the parties on November 28.
The court also received extensive documentary material in six volumes, including witness statements, medical records, audio and video recordings.
In one of the video recordings, Ms Ho said she felt like "nobody was listening to me. I asked for certain things to be done and was ignored".
Ms Ho has urged parents to insist on getting their questions and concerns answered in hospital.
"It doesn't matter how small the issue is, have it addressed and insist on getting answers. Nor does it matter how petty you think it is. The other recommendation is to make sure parents and family know about the REACH program," she said.
The REACH program encourages patients, family and carers to initially engage with their nurse or medical team, if they are concerned that 'something is not right'.
Ms Ho's message to parents is to cherish every moment their children.
"Even when you don't feel like it. I am one of many mothers that has lost a child, my only child and I would do anything to have her back with me," she said.
"Every parent is so blessed to have their children alive today, love and listen to them no matter what, she said.
"I do know that the Bowral Hospital staff and doctors involved in this tragedy, have been deeply affected and have since implemented numerous vital changes in policy and procedures. For this I am grateful and hope that they continue to be accountable for putting into effect the recommendations."
South Western Sydney Local Health District offered its sincere sympathy to the family and friends of Angelique Burton-Ho and said it was considering the coroners recommendations.
"The REACH program has operated at Bowral and District Hospital since 2013. Based on feedback from patients, families and carers, the program has been further developed this year," a SWSLHD spokeswoman said.
"Staff routinely inform patients and families about the program, and how to access it, and information about the program is displayed around the hospital."
