AN INQUEST heard how a man died after a mistake by the doctor at the centre of the probe into baby Aleesha Evans' death.

Dr Salawati Abdul-Salam sent patient Colin Perriam home from Cardiff's University Hospital for Wales in December 2004 after wrongly diagnosing a case of constipation. He died days later from a perforated ulcer.

The coroner concluded yesterday that nine-month-old Aleesha Evans would have survived the blood poisoning that killed her if a doctor had not ignored Royal Gwent Hospital policy and sent her home with prescriptions for Calpol and Nurofen.

After the inquest into that patient's death, during which she took evidence from Dr Abdul-Salam, Cardiff coroner Mary Hassell said she sent a letter about her to the hospital and to Cardiff and Vale NHS Trust bosses.

This was late in June 2006, just weeks before Aleesha Evans' death that August. By then, Dr Abdul-Salam was working at the Royal Gwent and had made other clinical errors.

Aleesha was taken to the Royal Gwent by parents Shiree Hanbury, of Bettws, Newport, and Craig Evans, on August 9 2006, after being sick and developing a temperature and a small tummy rash.

They were worried about the possibility of meningitis, but despite their concerns, a high temperature that had increased despite a dose of Nurofen, and a heart rate persistently higher than usual, she was sent home. Fifteen hours later she was dead, of blood poisoning caused by meningococcal infection.

Junior doctor Owen Rees, who first examined Aleesha, and Dr Abul-Salam, from whom Dr Rees sought advice after he could not make a definitive diagnosis, disagreed over the events leading to Aleesha's discharge.

Dr Rees insisted he put the observation chart containing information about the temperature and heart rate down in front of Dr Abdul-Salam, She insisted he had not.

"One of them must be wrong and I find Dr Rees' version the one most likely to be truthful and accurate," said Mrs Hassell, who returned a narrative verdict on Aleesha's death.

"I accept he took the chart to Dr Abdul-Salam and put it down in front of her. I cannot see why her version of events was not accurate. She may have mis-remembered.

"Sometimes when we look back we cannot believe what we have done. It may simply be that she is not telling the truth."

Under hospital policy it was mandatory that a child under five years old presenting with fever without focus, (that had eluded specific diagnosis), be referred to a paediatrician. This was not followed and Aleesha was discharged.

"The system in place said very clearly that in these cases there should be a referral," said Mrs Hassell.

Having taken evidence from Dr Ian McConachie, consultant in paediatric emergency medicine and meningococcal disease expert, she said: "I accept the evidence that if antibiotics had been given the previous night, Aleesha Evans would have survived without injury."