A CORONER has found the death of a “bright and bubbly” toddler could have been prevented if they were treated appropriately at first admission at Northeast Health Wangaratta (NHW).
The findings of coroner Katherine Lorenz were presented at Coroners Court Melbourne on Tuesday into the December 30, 2021, death of a 19-month-old toddler who had been visiting the area on holidays with his family.
Ms Lorenz said had the severity of his illness been recognised and if the parents of the toddler had been listened to, he likely would have survived.
While on holiday in Myrtleford on December 29, the toddler’s parents woke early in the morning to find the toddler unwell, having vomited and had a high fever.
He remained unsettled, distressed, cried for some hours and refused his bottle before being admitted to Alpine Health and handed over to Wangaratta.
Latest Stories
The family arrived in Wangaratta at around 3:45pm, with the “usually interactive” 19-month-old drowsing off, looking dehydrated and continually vomiting on the ride from Myrtleford.
Paul Bumford, a locum doctor who was 10 minutes into his first shift at NHW assessed the toddler as his first patient.
Dr Bumford diagnosed the toddler as having gastro, when he in fact had meningitis.
His vital signs showed he had a temperature of 39.4 degrees and appeared drowsy, febrile, lethargic and unwell
He was prescribed an immediate dose of ondansetron for nausea, along with paracetamol and ibuprofen.
After noting improvement since treatment, Dr Bumford discharged the toddler at around 7:20pm.
During the inquest, the doctor made concessions of his failings to care for the toddler.
Ms Lorenz said it was clear Dr Bumford’s induction to the emergency department at the hospital was inadequate and rushed, conducted in the circumstances of an overwhelmed and understaffed department.
Following the toddler’s discharge from Wangaratta hospital, he was taken to Benalla Urgent Care Centre by his parents as they observed his deteriorating condition.
The toddler was then transported back to Wangaratta by ambulance and was extremely unwell, hypotonic, and suffering seizures.
Scans showed he had signs of meningitis and was dispatched to the Royal Children’s Hospital.
He was later confirmed brain dead at around 3:10pm on December 30.
Ms Lorenz accepted it was a “difficult point” in the COVID-19 pandemic which had an impact in the way care was provided and Dr Bumford was at great disadvantage due to being 10 minutes into his first day at the hospital.
“It was conceded by NHW that the toddler should not have been discharged,” she said.
“Discharging the toddler in these circumstances was a clear failure of NHW’s duty of care.
“Had his parent’s been listened to, then the toddler’s care would have and should have been escalated early in his first admission to NHW.
“This is likely to have changed his outcome.”
Ms Lorenz said many of the issues prevalent in the care of the toddler had been addressed by NHW, but the emergency department continued to face issues of under staffing, particularly over long weekends and holiday periods.
Ms Lorenz recommended changes to better recognise parental and carer concerns as a core vital sign in patients when being assessed by clinicians.
“I wish to convey my sincere sympathies to the parents for their loss,” she said.
“His death was a heartbreaking and life altering tragedy for them and their family and friends.
“I commend them both for courageously pursuing an inquest to ensure that his death had an appropriate and necessary public inquiry about the failings in care.
“At every stage of the investigation, they have shown remarkable fortitude, patience and integrity, and remained faithful to his memory.”
Northeast Health Wangaratta provided the following statement to the Wangaratta Chronicle, following the coroner's findings into the death of 19-month-old Noah Souvatzis.
"Our thoughts and condolences continue to be with Noah’s family.
"NHW accepts that Noah did not receive the care he should have, something that rightly weighs very heavily on us as a health service.
"We thank the coroner for their findings, which we will now review and we are committed to implementing any further improvements."
