Two-year-old Callie was white as a ghost and could not keep her eyes open.
Her panicked mother knew something was wrong.
She called the Royal Children's Hospital in Melbourne to ask for urgent medical advice.
"Whoever I spoke to said that they would contact a surgeon and they would call us straight back," Natalia Griffiths-I'Anson told an inquest.
But no one returned her call.
Hours later, Callie's parents awoke to the startling noise of their toddler gurgling.
She was limp and had stopped breathing.
Paramedics tried to revive her but she died in hospital.
A Victorian coroner has found RCH's failure to call the family back was "wholly inadequate" and recommended changes to the hospital's procedures.
Callie was initially brought to the hospital in December 2017 after ingesting cleaning liquid at the Oaklands Hotel in NSW.
She had gained access to the bar area while her mother, who worked at the pub, was paying bills at a nearby post office and ingested caustic alkali liquid used to clean soda glasses.
Callie, struggling to breathe with bleeding lips, was flown to the Melbourne hospital, nearly four hours' drive away.
She was put into a medically induced coma before being transferred out of intensive care, and was released in early January 2018.
Less than a week later, on January 11, Callie and her parents returned to the hospital for a fourth procedure on her oesophagus.
Five weeks post-injury, her oesophagus had not yet healed and still had a significant amount of bleeding.
After the operation, Callie was cleared to return to their home in Oaklands, but that evening her condition worsened.
Ms Griffiths-I'Anson called the hospital switchboard for urgent help at 10pm, after being given that number when Callie was discharged.
The worried parents waited for a call back but were exhausted, so placed Callie between them in bed.
At 6am, they woke up to the sound of Callie gurgling.
They called triple zero and paramedics tried to revive her, but the two-year-old died at Corowa District Hospital on January 12.
RCH conceded the family did not receive a call back before Callie died because it had been put through to an on-call surgical registrar, who was busy in a major procedure that night.
An internal hospital review found the registrar finished at 1am but felt it was too late to call the family then, planning to call first thing in the morning.
In findings released this week, coroner Paresa Antoniadis Spano said this response was inadequate and recommended RCH develop better processes.
This included that the hospital use technology to re-route calls, ensure the person who takes the calls is qualified, triage and differentiate such calls and use structured questioning when answering.
Additionally, that call takers take into account the vulnerability of a child patient if they live in a rural area such as Callie, where the nearest paramedic station is 40 minutes' drive away.
