Doctors say the coroner's findings into the death of Dunedin toddler Hineihana Sosefina Mausii demonstrate the need for change.
A coroner says the two-year-old was let down by a system which allowed for her to only be assessed by an inexperienced junior doctor under inadequate supervision, despite the concerns of her parents.
RNZ Otago-Southland reporter Timothy Brown has more.
