A schoolgirl starved herself to death as the result of an undiagnosed psychological syndrome, a coroner ruled today.
Sophie Waller suffered an apparent extreme dental phobia and refused to eat, sleep or drink after her milk teeth came loose.
The eight-year-old from St Dennis, Cornwall underwent an operation to remove all eight of her milk teeth but this failed to cure the problem and she died on 2 December, 2005.
The coroner for Cornwall Dr Emma Carlyon, who recorded a narrative verdict, said the severity of her condition was not realised and this "prevented her from receiving the medical support that could have prevented her death".
arlyon said: "I find that the cause of death was the result of acute renal failure due to dehydration and starvation.
"Sophie's death was influenced by an underlying, undiagnosed psychological condition.
"The severity of the condition was not realised, this prevented her from receiving the medical support that could have prevented her death."
Dr Carlyon said she would be sending her findings to the local safeguarding children's board.
Sophie's parent's, Janet and Richard Waller, said they regretted listening to the advice of health professionals.
In a statement, the couple said the three year waiting for the inquest was an "emotional and distressing time".
They said: "No words can express how we have felt and still feel.
"Our only regret is that we listened to the advice given to us by professionals and did not follow our own hearts."
Sophie was admitted to hospital on 7 November and underwent the operation to remove her milk teeth two days later.
She was kept in and fed through a drip before being released to go home for a weekend on November 18.
The inquest heard that after she seemed to respond positively at home and after a physical and psychological assessment on 21 November she was officially discharged.
Her notes were then sent to the wrong GP and she was not seen by another medical professional before she died, the hearing was told.
After the verdict, the hospital apologised to the family.
Medical director Dr Ellen Wilkinson said: "Everyone involved in Sophie's care was saddened by her tragic death. We would like to apologise to her family.
"This was a very unusual case. We have conducted a review of her care and are carrying out recommendations."
The inquest, at Truro City Hall, heard Sophie was so emaciated in the days before her death her spine was clearly visible through her skin and her hair was falling out.
The court was told doctors at the Royal Cornwall Hospital failed to properly organise her post-hospital care and when Mrs Waller rang to ask to return her to the ward on 28 Novembershe was referred back to the community clinical psychologist.
Dr Arnon Bentovim, consultant child psychiatrist, said it was an opportunity to save her that was missed.
He told the court: "At the point when the parents phoned the ward, and were clearly anxious enough to do so, had that anxiety been picked up then there would have been an opportunity for the death to be prevented.
"There was a failure to ensure that her ongoing medical care was fully managed and planned.
"There needed to be a joint physical and psychological follow-up; it was optimistic to believe that the initial positive response was necessarily going to mean that this child would make a reasonable recovery."
Dr Bentovim also said it was possible for Mrs Waller to be trying to feed her daughter and not realising she was not swallowing the food.
Dr Charles Holme, consultant paediatrician, said Sophie's situation was so rare and unusual a GP should have been contacted directly and briefed on the case when she was discharged and a care plan set up where she was weighed and checked regularly.
He said: "It would have been easy to have just picked up the phone and spoken to a GP, that was not done.
"This young lady presented in a very unusual way, because of that the GP should have been spoken to on discharge.
"It seemed to me to be an unsatisfactory way of doing things."
He also told the inquest a full psychological assessment of Sophie should have been carried out before the operation to remove all her milk teeth.
He said: "A full assessment was not carried out prior to what was a very major procedure for a small child."
In her conclusion, Dr Carlyon said she was "pleased" all the agencies involved had carried out their own independent reviews and changes were made.
Mrs Waller said she hoped any changes which were implemented "will hopefully save another child's life".
She said: "We have had to live with this since the day Sophie died and will continue to live with it for the rest of our lives."