The B.C. Coroners Service says there wasn't any wrongdoing in the death of a toddler who died in hospital on a return visit, one day after being discharged from the emergency room.
Nimrat Gill died of sepsis caused by Group A streptococcus pneumonia — a "relatively uncommon" infection with a high mortality rate, according to the report.
Coroner Adele Lambert said it was a natural death, and made no recommendations.
Gill's parents first took her to the emergency room at Abbotsford Regional Hospital on Feb. 6, complaining of fever, coughing and vomiting.
The toddler was discharged and sent home, but her parents brought her back the next day when her condition deteriorated. The toddler died in hospital a few hours later.
Gill's mother, Balraj, said she suspected her daughter had pneumonia from the start.
The B.C. Coroners Service confirmed it would be investigating the death in late February.
Fraser Health, the agency overseeing the hospital, ran its own patient and safety review after Gill's death.
The health authority also came up with six actions following their review of Gill's death. These include sepsis screening for all pediatric patients whether or not they are showing symptoms, regular simulation training in pediatric emergencies, and an investigation of shift change and escalation processes in the Abbotsford emergency department to see whether further improvements can be made.
It also said lab tests showed the toddler had a "fast-moving" and "aggressive" strain of the group A disease.
The disease usually causes mild illnesses such as strep throat or a mild skin infection, but it can also invade parts of the body where the bacteria are not found — such as the lungs or blood — on rare occasions. Those infections are potentially life-threatening.
Lambert found that Gill, who was three years old when she died, had the disease in her lungs. She wrote that the illness progression "is often unexpected and rapid in nature."
Lambert said the toddler also had an upper respiratory tract infection, which may have contributed to her death.