Death of Noah Souvatzi: Doctor Paul Bumford showed up for his very first locum shift at a new hospital. Then he made a devastating decision that would change the lives of a family forever

A devastated doctor who discharged a seriously ill toddler from hospital, leading to his death, has revealed what went wrong.

Doctor Paul Nicholas Bumford told the coroner at the inquest into the death of 19-month-old Noah Souvatzis that he believed the child had gastrointestinal problems when he examined him at Wangaratta Hospital on December 29, 2021.

Doctor Bumford, who was working at the Victorian hospital for the first time, discharged little Noah just three and a half hours later. But the toddler and his parents returned shortly afterwards when his condition deteriorated dramatically.

Noah was then flown to the Royal Children’s Hospital and the toddler was declared brain dead at 3.11pm on December 30.

His life support was turned off on December 31 after the toddler’s organs were donated.

Despite Noah Souvatzis (pictured with his father Ben) vomiting during his discharge from hospital, he was sent home. The toddler’s condition worsened and his parents returned him hours later

Doctor Paul Nicholas Bumford (pictured leaving the inquest into Noah Souvatzis’ death on Tuesday) told the coroner in retrospect he wished he had consulted a doctor with more experience.

Dr. Bumford told the coroner Tuesday that, in retrospect, he wished he had asked a more experienced doctor to evaluate Noah. The age reported.

He also said he wished he had done further checks and referred Noah to the children’s team to keep him under observation for longer.

‘Since his condition had improved, I thought it fair to discharge him. I am devastated by (the) outcome,” Dr Bumford said.

The Coroners Court heard from other witnesses who said Wangaratta Hospital had chronic staff shortages, long ambulance wait times, internal conflict and that employees lacked experience and seniority.

Covid restrictions were in place in parts of Victoria at the time, which also exacerbated pressure on the health sector.

Triage nurse Read Moreland had tears in her eyes as she told the coroner: ‘It was quite horrible.’

“I still remember that day,” she said.

Noah Souvatzis (pictured) was declared brain dead and his organs were donated

The Souvatzis family (pictured) were on holiday in regional Victoria when 19-month-old Noah became unwell

The nurse said the days leading up to Noah’s arrival were a “storm” and recalled texting others her concerns.

“I don’t know if we’ll all survive…the next few weeks/months.”

Ms Moreland told the inquest while everything in the hospital had been kept under control during the lockdowns, once everything reopened no additional resources had been provided to help with the extra workload of holidaymakers.

The triage nurse also said it had become common to hear about patients who had tried to get an ambulance but were told it would be quicker to drive in themselves, which is what happened in Noah’s case.

Ms Morehead described ambulance wait times as ‘scary’ for patients and ‘us sometimes’.

The toddler’s parents, Ben and Steph Souvatzis, were on holiday in the area and previously told the coroner that they were forced to take their increasingly ill boy to various health care services repeatedly and were usually turned away.

Wangaratta Hospital (pictured) was described by a triage nurse as understaffed at the time and as a ‘s**tstorm’ in the days leading up to Noah’s arrival at the emergency department.

The family first arrived at Alpine Health Care Center in Myrtleford at around 2.30pm but were sent to Wangaratta Emergency Department at around 3.45pm.

They were then discharged from Wangaratta at around 7.20pm, with Ben Souvatzis telling the inquest that Noah was a sicker child than they arrived with.

Mr Souvatzis had recalled to the court that panic and disagreements among staff were rife as he cared for a semi-conscious Noah in the emergency department queue.