A coroner has "for the first time ever" called for a doctor's licence to be suspended.
Coroner Dr Sean Cummings made the indication when delivering a narrative verdict on the death of Freya Wells, from Wallington, at Kingston Hospital.
He called the failure to recognise and treat Freya's "obvious" septic shock when she arrived at A&E and later on the Sunshine ward both gross, and "flagrant and extreme".
Dr Cummings said he will write to the General Medical Council "asking that Dr [Rosita] Ibrahim's licence be suspended pending a review into her performance."
It was the first time he had taken this course of action as a coroner, he said.
He added that Freya's death, at age four, was "wholly avoidable" and that registrar Dr Ibrahim was "out of her depth" on the night of November 21, 2012.
He told Freya's mother, Carly Wells: "This has been an awful time for you. I've been thinking about what I might say to you and in all honesty I can't think of anything that is going to be remotely sensible.
"You have been very dignified, you have been very brave.
"I'm terribly sorry. I just am very sorry."