The parents of a 19-month-old boy who died after being wrongly discharged from hospital wept in court after a coroner ruled his death could have been prevented.
The Souvatzis family were on holiday in north-eastern Victoria on December 29, 2021 when Noah developed a high fever and began vomiting.
His parents, Ben and Steph, took him to an emergency room in the city. An Alpine Health nurse noticed symptoms of lethargy and an increased heart rate.
On the advice of the nurse, Noah was taken to Wangaratta Hospital, where Dr Paul Bumford diagnosed him with gastrointestinal symptoms. He was discharged three hours later, despite continuing to vomit.
Noah’s condition deteriorated, so his parents took him to another medical centre in Benalla a few hours later. Noah was then taken back to Wangaratta Hospital by ambulance.
The boy suffered seizures en route and CT scans showed signs of meningitis, so Noah was flown to the Royal Children’s Hospital in Melbourne in the early hours of December 30.
At 3:11 p.m. that day, Noah was declared brain dead and died the next morning.
Coroner Katherine Lorenz ruled on Tuesday that Noah’s tragic death could have been prevented and he should not have been discharged from Wangaratta Hospital in the first place.
Noah Souvatsis (pictured) was on vacation with his parents when he developed a high fever and started vomiting
Noah’s parents, Ben and Steph Souvatzis (pictured leaving the coroner’s court on Tuesday) wept as the findings were handed down. The coroner praised the Souvatzis family for their courage in launching an investigation
“Wangaratta Hospital clearly failed in its duty of care to Noah,” Lorenz said.
Ben and Steph Souvatzis wept in the coroner’s office as the findings were announced.
Mrs. Lorenz noted that Dr. Bumford was on his first shift at the hospital and was in the middle of an induction session when he went to assess Noah.
He was to be second in charge of the emergency department, but he did not have enough experience for that role, the coroner concluded.
The more experienced chief physician Doug Devereux should have examined Noah or at least reviewed his medical records before dismissing him, Lorenz said.
But Dr Devereux gave Noah “no more than a glance”, even though photographs taken that day clearly show Noah was very unwell and not alert, the coroner said.
Dr. Bumford admitted at the inquest that he had misdiagnosed Noah and the coroner concluded that the toddler might have survived if he had been given antibiotics during his initial hospital admission.
Mrs. Lorenz also learned that Noah’s outcome could have been different if doctors had listened to Ben and Steph Souvatzis when they expressed their concerns about their son’s condition.
“Parents know their children best,” she said.
Coroner Katherine Lorenz ruled that the 19-month-old baby’s death could have been prevented (pictured are the Souvatzis family)
The coroner said that “parents know their children best” and that Noah’s tragic outcome could have been different if doctors had listened to his parents’ concerns (pictured Noah Souvatzis)
The coroner advised the Australian Commission for Health Care Safety and Quality and Safer Care for Children to advise doctors to ask for and record parental concerns when routinely checking a child’s vital signs.
Mrs Lorenz praised the Souvatzis family for their courage in launching an investigation into this heartbreaking and life-changing tragedy.
The couple did not speak to reporters but gave a statement in court through their lawyer, thanking the coroner for listening to them after years of silence.
A spokeswoman for Northeast Health Wangaratta said the hospital’s thoughts and condolences remain with the Souvatzis family.
“NHW acknowledges that Noah did not receive the care he should have received, something that rightly weighs heavily on us as a health service,” the statement to AAP said.
“We thank the coroner for his findings. We will now review them and are committed to making further improvements.”