Rozalia Spadafora inquest: mistakes and miscommunication in 5yo’s death

The ACT Coroner's Court inquest has found a lack of communication and preventable mistakes among Canberra Hospital's staff led to a delay in her diagnosis and, ultimately, Rozalia's death.

The five-year-old is believed to have died of myocarditis brought on by influenza A in July last year – a day after her fifth birthday.

She was taken to the hospital's emergency department on the advice of a GP who had been treating her.

But Rozalia's mother and grandmother said they waited for hours despite her deteriorating condition and weren't taken seriously after nurses gave Rozalia water, Hydralyte, and Panadol.

"Please take mothers seriously when we come in there with our children," Rozalia's mother told A Current Affair last year.

Rozalia underwent a number of tests and shifted multiple times around the hospital.

A decision was made to transport her to Sydney for specialist treatment, but she died from cardiac arrest – 28 hours after her admission.

Rozalia's mother said they were kept in the dark until it was too late.

"We lost our daughter at Canberra Hospital. No one helped her until it was too late. No one told us what was happening before it was too late," she said in a statement.

"My family has no answers, and we are broken."

"This was an entirely avoidable incident with consequences that will now last a lifetime."

Dr Tze Hoa Wong, who was the first doctor to treat Rozalia, told the inquest he wasn't particularly surprised she waited for five hours in the ED despite being triaged as category three – an urgent patient who should have been seen within 30 to 45 minutes.

That night, Dr Wong was the only paediatric emergency doctor responsible for six beds and two consultation rooms within the ED.

However, he agreed with the coroner when asked if he could have been called to another more urgent patient.

Evidence by Dr Wong appeared to reveal poor communication between the paediatric and ED

Dr Callum Jarvis, a children's doctor from another hospital, told the coronial inquest he was concerned Rozalia needed more help than what was available at the current paediatric ward.

"We had a very unwell child that was likely to need further treatment, possibly including heart medication," Dr Jarvis said.

He said he spoke to intensive care unit doctors, but they did not want to review the five-year-old before senior paediatrician Dr Anne Mitchell assessed her.

Dr Jarvis thought these doctors were reluctant because they did not often care for children in the ICU.

Senior paediatrician Dr Anne Mitchell cried when asked by the coroner how the death impacted her.

"It had a significant effect," she said.

"I cannot imagine how her family cope."

"I'm very, very sorry that this happened to her."

Dr Mitchell became involved with Rozalia's care almost 12 hours later, just before 6am on the day Rozalia died.

She ordered a test an hour later that would confirm Rozalia had myocarditis.

The results came back at 10am. However, Dr Mitchell wouldn't see it until midday.

"I would've expected a quick turnaround on that test," she said.

The result was found handwritten on a sticky note inside Rozalia's file, which upset Dr Mitchell.

"I recollect being surprised it had come back earlier, and I wasn't alerted," she told the coroner.

"It was a highly significant result and should have been acted on when it was received."

Registered nurse Sarah Retford told the coroner that she notified other nurses and moved Rozalia to another bed, which she had been asked to do when she found the sticky note after 8am.

"Minutes" after moving Rozalia, Ms Retford said she informed two paediatric doctors, Dr Jade Stewart and Dr Aidan Watters, of the result.

Dr Stewart told Ms Retford to call if Rozalia got any worse and left.

Two consultant doctors, the most senior position in the ED, gave conflicting accounts about who was responsible for overseeing Rozalia's care.

Both were questions about a July 5 roster document, with a pre-filled section indicating Dr Amy Ting was responsible for overseeing R1 and R2 – two beds in the resuscitation ward, which included Rozalia's.

A note, however, written in pencil indicated she would be covering a different section.

Previously, a nurse working on the ward during Rozalia's death said reallocations were common and could happen due to staffing levels or how sick each patient was.

The nurse also said it could happen during a shift, but she was more likely to refer to the allocation at the bottom of the page, which Dr Ting was working off.

The coroner questioned the inconsistency, asking Dr Ting if this was a bad system.

"But the inconsistency leads to the change that R1 and R2 would not be covered by a consultant, do you agree?"

"Correct," Dr Ting said.

Dr Ting then told the court Kirsty Dunn was responsible for seeing Rozalia.

Dr Dunn said she interpreted the sheet as giving Dr Ting responsibility due to the hand-written addition.

When asked if Dr Dunn understood the day sheet to give her responsibility for Rozalia, she became emotional.

"No, I'm sorry, I did not," she cried.

"I'm so sorry, I feel terrible."

The coroner ended Dr Dunn's evidence early, judging she was in no state to continue.

"The last thing we want is for these proceedings to cause you unnecessary distress," he said.

"There was a legitimacy for confusion."

"This has caused you great distress, I'm sorry for that."

The first block of hearings finished as the coroner addressed Rozalia's parents and family in the gallery afterwards.

"It's been a fairly confronting sort of experience," he said.

"I think it has been for everybody in the room, frankly."

"Everybody feels for you and your loss."

The next block of hearings will commence in early December for a week.

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