Callie Griffiths-I’Anson inquest: Coroner recommends changes at Royal Children’s Hospital Melbourne

An inquest has handed down its findings about the tragic death of a little girl five years ago, ruling a hospital’s failure to recall the toddler’s family was “completely inadequate.”

Mother Natalia Griffiths-I’Anson knew something was terribly wrong when she noticed that her two-year-old Callie was white and couldn’t keep her eyes open.

The frantic mother called Melbourne’s Royal Children’s Hospital late at night to seek urgent medical advice, hours after Callie was discharged following a procedure.

“Whoever I spoke to said they would contact a surgeon and they would call us right back,” Ms Griffiths-I’Anson told the inquest into her daughter’s death.

But no one called back. Hours later, Callie’s parents awoke to the startling sound of their toddler gurgling. She was limp and not breathing.

The toddler died later that morning at a southern NSW hospital, 16 hours after she was discharged from RCH.

Five years later, a Victorian coroner determined that RCH’s failure to call back Callie’s family was ‘completely inadequate’ and recommended changes to the hospital’s procedures.

Recommended changes included better advice to parents about their children who have had recent procedures.

But coroner Paresa Spanos also ruled that it was reasonable for Callie to be released from RCH Melbourne, despite the fact that he died of surgical complications the next day.

“The discharge plan as documented in the medical record and as explained to parents prior to discharge was reasonable and appropriate,” she wrote.

“At the time of Callie’s discharge, there was no clinical evidence that she was unwell, unfit for discharge, or had suffered an iatrogenic perforation or any other complication of the procedure.”

Callie was initially taken to RCH in December 2017 after ingesting cleaning fluid at the Oaklands Hotel in NSW.

She had been allowed access to the bar while her mother, who worked at the pub, paid bills at a nearby post office and ingested caustic alkaline liquid used to clean soda glasses.

Callie, who was struggling to breathe with bleeding lips, was airlifted to Melbourne hospital, nearly four hours away.

She was placed in an induced coma before being removed from intensive care and 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 esophagus.

Five weeks after the injury, her esophagus had not yet healed and she was still bleeding profusely.

Callie Griffiths-I’Anson tragically died one day after being released from the hospital

Callie’s mother called Melbourne’s Royal Children’s Hospital for urgent medical advice and was told someone would call her back. The hospital never called back and the toddler died hours later

After surgery, Callie was cleared to return to their home in Oaklands, but her condition worsened that evening.

Mrs. Griffiths-I’Anson called the hospital switchboard for urgent help at 10 p.m., having been given that number when Callie was discharged.

The concerned parents waited for a call but were exhausted, so they put Callie in bed between them.

At 6am, they awoke to the sound of Callie gurgling.

They called triple zero and paramedics tried to resuscitate her, but the two-year-old died on January 12 at Corowa District Hospital.

RCH admitted that the family was not called back before Callie died because it was put through to a surgical registrar on duty, who was busy with a major procedure that evening.

A coronial inquiry into Callie’s tragic death ruled the hospital’s failure to call back the toddler’s family as ‘completely inadequate’

An internal inquiry at the hospital found that the clerk finished at 1 a.m., but felt it was too late to call the family by then, as he intended to call first thing in the morning.

In findings released this week, coroner Paresa Antoniadis Spano said this response was inadequate and recommended that RCH develop better processes.

This included the hospital using technology to route calls, ensuring that the person taking the calls is qualified, triaging and differentiating such calls, and using structured questions when answering.

In addition, those callers consider the vulnerability of a child patient if they live in a rural area, such as Callie, where the nearest paramedic station is a 40-minute drive away.

RCH Melbourne will review the findings and respond to the coroner’s recommendations.

“The Royal Children’s Hospital extends its deepest condolences to Callie’s family,” a spokeswoman told the Daily Mail Australia on Wednesday.

“There can be no greater sorrow than the loss of a child. We will review the findings and respond to the coroner’s recommendation. ‘

Callie (pictured) died a day after being discharged from Royal Children’s Hospital Melbourne following surgery