Aishwarya Aswath died on Easter Saturday 2021, hours after presenting to the Perth Children's Hospital emergency department with a fever and unusually cold hands.
She had been left in a waiting room for more than 90 minutes, despite her parents pleading with staff - who they described as rude and dismissive - to escalate care as her condition deteriorated.
An inquest into her death was told there was intense demand on staff who missed repeated opportunities to identify the seriousness of her condition.
Premier Mark McGowan has insisted the hospital was not understaffed on the night Aishwarya died because it had its full rostered complement.
But in her long-awaited written findings on Friday, Deputy State Coroner Sarah Linton said while that was "technically" correct, it had been made apparent the roster had been inadequate to deal with demand.
"Aishwarya's parents brought their daughter in to hospital because they knew she needed help," Ms Linton said.
"But due to the pressures on them, the medical and nursing staff missed the signs that she was critically ill from sepsis and failed to rescue her.
"It really is as simple, and as tragic, as that."
Ms Linton did not make any individual adverse comment against the staff members involved in Aishwarya's treatment.
The coroner has formally backed several recommendations put forward by the Australian Nurses Federation.
These include the priority implementation of nurse to patient ratios without waiting for an industrial agreement between the union and state government to be registered.
Ms Linton has also recommended enhanced waiting room protocols to provide better monitoring of signs of sepsis, better access to digital record-keeping tools and the staffing of a standalone resuscitation team in the Perth Children's Hospital ED.
She noted there were multiple opportunities on the night where clinicians could have escalated Aishwarya's care, had they stopped to consider her symptoms more closely and listen to the repeated concerns being raised by her parents.
The "most significant" arose when junior waiting room nurse Tahnee Vining observed Aishwarya to be grunting in pain with an elevated heart rate, respiratory rate and temperature.
Ms Vining did not consider sepsis, despite Aishwarya meeting the documented threshold for further investigation.
The nurse was unable to monitor Aishwarya because she was repeatedly called away on other duties, including assisting a patient resuscitation.
Had proper treatment been initiated during that time, there was a "small possibility" Aishwarya's life might have been saved, Ms Linton said.
"That chance, albeit statistically small, was enormously significant to Aishwarya's family."
A nurse had raised concerns in an email to their union in March 2021 about the hospital's staffing levels, and Ms Linton said it appeared then-health minister Roger Cook had also been generally informed of the situation.
"It is deeply concerning to then see these events play out only a few days later, exactly as the nurse had feared," the coroner said.
"The background points to systemic issues surrounding the resourcing of the ED, rather than the behaviour of individuals in this case."
While the state government had implemented various changes to improve Perth Children's Hospital, it was too late for Aishwarya and her family.
"It shouldn't take the death of a beloved little girl for ... the government to stop and consider what more it can do, and how much more money it should spend, to keep children safe when they visit our specialist children's hospital," Ms Linton said.
"There is no point in having a state of the art facility, if the staff working within it are stretched beyond capacity and parents lose their trust and faith in them."
Ms Linton paid tribute to the "grace and dignity" of Aishwarya's father Aswath Chavittupara and mother Prasitha Sasidharan, adding that she understood why they would "never forgive" the health system.
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