Inquest into the death of Rozalia Spadafora

[2024] ACTCD 8

CORONER’S COURT OF THE AUSTRALIAN CAPITAL TERRITORY

Matter Title: 

Inquest into the death of Rozalia Spadafora

Citation:

[2024] ACTCD 8

Decision Date:

6 December 2024

Before:

Coroner Archer

Findings:

See [274]-[275], [278], [279]-[308]

Catchwords:

CORONIAL LAW – manner and cause of death – myocarditis – delayed diagnosis – gaps in paediatric care at the Canberra Hospital – inconsistent handovers – lack of a cohesive clinical care framework – unrecognised ECG abnormalities – delayed troponin test results – Clinical Initiatives Nurse (CIN) – infrastructure for paediatric care – Influenza vaccination

Legislation Cited:

Coroners Act 1997 (ACT) ss 3BA, 13, 34, 39, 39A, 52, 55, 57

Case Cited:

R v Doogan; Ex parte Lucas-Smith [2005] ACTSC 74

Representation:

Counsel Assisting the Coroner

M Fordham SC (with S Richards as Solicitor Assisting the Coroner)

Counsel for the Family

D Shillington (instructed by BAL Lawyers)

Counsel for the Australian Capital Territory

M Gerace SC & E Aitken (instructed by ACT Government Solicitor)

Counsel for Dr Anne Mitchell

J Sandford (instructed by MDA National)

Counsel for Dr Khaleda Yesmin and Dr Kirsty Dunn

J Nottle (instructed by MinterEllison)

Solicitor for Dr Mitchell Wilcox, Dr Aidan Watters, and Dr Conan Hall

H McCay (Avant)

Counsel for Dr Jade Stewart

T Berberian (instructed by MDA National)

Counsel for RN Lucinda Reumer

K Musgrove (instructed by Snedden Hall & Gallop Lawyers)

Counsel for Dr Abinesh Dhital and RN Sarah Retford
K Pattenden (instructed by Moray & Agnew)

File Number:

CD 187 of 2022

EXECUTIVE SUMMARY

Rozalia Spadafora died in the Canberra Hospital at 2252 hours on 5 July 2022. She died the day after her fifth birthday. Her death was caused by myocarditis, which is rapid onset inflammation of the heart muscle brought on, in this case, by influenza A. Myocarditis is a rare condition.

Rozalia was brought to the Emergency Department (ED) at the Canberra Hospital (“TCH”) at approximately 1900 hours on 4 July 2022, having been unwell in the preceding days.

Evidence given by treating clinicians and independent experts indicated that while appropriate testing was eventually undertaken, the diagnosis of myocarditis, which eventually occurred at 1220 hours on 5 July 2022, was unreasonably delayed for the following reasons:

(a)    After presentation at the ED at TCH, Rozalia was not seen by a doctor until 0016 hours on 5 July 2022. According to her triage category, Rozalia should have been seen within 30 minutes;

(b)    Safety net processes that existed to ensure patients were seen within triaged timeframes were absent, apparently because of staffing and resource issues;

(c)    An ECG indicating cardiac abnormality was misread in the morning of 5 July 2022;

(d)    Symptomology consistent with myocarditis was not appropriately assessed;

(e)    A blood result for troponin was not produced in an acceptable timeframe, and when it was, it was not acted upon; and

(f)    There was a lack of a cohesive and co-ordinated process of care as between clinicians from different areas of TCH.

There was sufficient information by around 0740 hours on 5 July 2022 for a diagnosis of myocarditis to be made.

The delay in diagnosing myocarditis meant that by the time it was determined that Rozalia required transfer to Sydney for intensive care treatment, she was unable to be stabilised sufficiently for the journey.

The following matters of public safety arose from the evidence given in the inquest:

(a)    A lack of timeliness in Rozalia being reviewed by a doctor in the Emergency Department and a lack of staffing resources to ensure that risks associated with a delayed review by a doctor were mitigated by a process of ongoing observation and review by a Clinical Initiatives Nurse (CIN);

(b)    Inadequate levels of paediatric specialisation at TCH in the ED and Intensive Care Unit that would have allowed appropriate care to be provided to seriously unwell children such as Rozalia;

(c)    A lack of clarity about roles and responsibility for management of Rozalia’s care, including the existence of internally contradictory day sheets indicating allocation of beds to doctors; and

(d)    Vulnerabilities and a lack of timeliness in the system for processing, reporting and notifying urgent and add-on pathology results.

I make the following recommendations:

(a)    That Canberra Health Services (“CHS”) adopts a staffing model that ensures the position of Clinical Initiatives Nurse (CIN) is filled on a 24-hour basis and quarantines the position from the staffing demands of the ED;

(b)    That those involved in the implementation of the new ICU and the Paediatric ED, as well as the planning of the paediatric Close Observation Unit, consider the evidence in this inquest and these findings;

(c)    That CHS review the functionality of the Digital Health Records system in respect of handover processes, in light of the evidence given in this inquest; and

(d)    That CHS and ACT Health actively promote influenza vaccinations amongst children aged between 6 months and 5 years old.

CORONER ARCHER:

PART 1 – INTRODUCTION

1. Rozalia’s death is a tragedy for her family and many friends.

2. Many members of Rozalia’s family and family friends were present at the hearing.

3. During the investigation of Rozalia’s death, I received descriptions of her during her tragically shortened life. Katrina, Rozalia’s mother, was the first witness called at the hearing, and she spoke of her daughter movingly to a full courtroom. Her emotional pain filled the courtroom. I respectfully reproduce some of what Katrina said:

   Could you just tell his Honour a little bit about your daughter?---Rozalia was a beautiful, bright, bubbly spark of light. She was the first girl granddaughter in our family so she was the apple of everyone's eye. She was – had everyone wrapped around her little finger. She was an empathetic little person. She loved young and old alike. We could say that she was everyone's favourite just because it's just the way her personality was. She was always singing, dancing, just trying to make everyone happy. She was just the ray of sunshine in our lives. There was never a day that would go by with – you know, without her coming to call me her best friend and, 'Mummy, I love you so much' and she – she just would be with us all – me all the time in particular but, yes, me and my mum and just always wanted to be around family and just loved – loved life, loved her brothers, loved – brother, her little cousins, her older cousins. She just loved everyone. She was just a spark.

4. Video footage of Rozalia interacting with family and friends was played by the family. That footage was released to the media, and the grief of Rozalia’s family was undoubtedly shared by everyone who viewed it. Before it was played, Katrina spoke further:

   Yes. She was the type of girl that if you had an interest in something she would make sure that her interest would align with your interest so she could get to know that person better. I know that sounds strange with her being only four but it was just the way she was. She – she would make an effort with everyone, everyone. She was a special little girl.

5. During the hearing, I expressed my sincere condolences to Rozalia’s family and friends. I say again that I am sorry for the loss of their beautiful child, grandchild, family member, and friend.

6. The Australian Capital Territory (“the Territory”), through witnesses and in submissions, acknowledged that the care afforded to Rozalia by the Canberra Health Services (“CHS”) fell short of acceptable standards. The Territory apologised to the family and committed itself to addressing the causes of the shortfalls that were evident in Rozalia’s diagnosis and care.

7. I acknowledge the anger felt by the family in respect of CHS and, more generally, the ACT healthcare system. I also acknowledge their view that individual practitioners had failed to save their daughter and refused to take responsibility for failings in the standard of care they provided.

8. I must, however, proceed according to the law and the evidence before me, and make the findings I am required to make pursuant to the Coroners Act 1997 (ACT) (“the Act”). As I said in opening the hearing, my role was and is not to vilify individual medical practitioners. Rather, I had an obligation to ensure that the evidence of witnesses was appropriately tested and, through these reasons, provide an explanation as to why Rozalia’s diagnosis was delayed.

9. The role played by individual clinicians is considered as part of an assessment of the quality of care Rozalia received during her admission. The inadequacy of the care provided to Rozalia has been conceded by CHS. Clearly mistakes were made. However, my impression of the witnesses who were called at the hearing was that they were competent clinicians who cared deeply for the patients under their care. Their approach to the diagnostic puzzle that confronted them was sound in that a cardiac cause of Rozalia symptoms was considered and tested for. However, the diagnostic process was unreasonably delayed due to those acknowledged mistakes but also because of systemic factors that, in some instances, were outside their control. I acknowledge that the coronial process was confronting for them.

10. I observe that it was obvious to me that those responsible for Rozalia’s care before and after her admission to the Canberra Hospital (‘TCH”) and those who gave evidence at the hearing felt the tragedy of her death in a heartfelt way.

PART 2 – THE COURSE OF THE INQUEST

JURISDICTION

1. The ability of a coroner to exercise jurisdiction in relation to a death is not at large. Most deaths that occur in the community are accounted for outside the coronial process. A coroner can only investigate when the legislation gives them the power to do so.

2. The death of a child in a hospital setting does not automatically result in a referral to the Coroner’s Court. In each case, a determination is made by a clinician as to whether a medical certificate should be issued to certify the cause of death, or whether the death is otherwise of a type that attracts the operation of s 13 of the Act – for example, that the death may be the result of an operation or procedure.

3. In this case, the Australian Federal Police (“AFP”) were informed by staff members at TCH that the doctors responsible for Rozalia’s care were not prepared to issue a medical certificate to certify the cause of her death. The reasons for that reluctance were recorded by one of the treating clinicians as including:

   (a)their concerns as to the potential discordance between the working diagnosis of post-viral myocarditis and the rapidity of Rozalia’s progression into cardiac arrest; and

   (b)the concerns expressed by Rozalia’s parents as to whether Rozalia had a condition that pre-disposed her to myocarditis, and whether there were any opportunities to intervene earlier and to prevent the chain of events that led to her death.

4. There was a discretion vested in senior clinicians to refer Rozalia’s death to the Coroner (by not writing a medical certificate). Given the circumstances, that discretion was exercised thoughtfully and correctly. The advocacy of Katrina’s parents was influential in that decision to refer Rozalia’s death to the Coroner.

5. In the absence of a medical certificate, Rozalia’s death fell within the terms of s 13(1)(e) of the Act. As the relevant Coroner,[1] I am required to hold an inquest into the manner and cause of her death.

   [1] Under the Act, a magistrate is a coroner for the Territory. The concept of a “dedicated coroner’ is not reflected in the terms of the Act. The concept is given expression by an allocation decision made by the Chief Magistrate to give one Magistrate primary responsibility to exercise the functions of a coroner, as set out in the Act.

REQUIRED FINDINGS

1. Section 52 of the Act sets out the findings I am required to make. Relevantly, that section of the Act provides:

   52Coroner’s findings

   (1)A coroner holding an inquest must find, if possible—

   (a)the identity of the deceased; and

   (b)when and where the death happened; and

   (c)the manner and cause of death; and

   (d)in the case of the suspected death of a person—that the person has died.

   --

   (4) The coroner, in the coroner’s findings—

   (a)must—

   (i)    state whether a matter of public safety is found to arise in connection with the inquest or inquiry; and

   (ii)    if a matter of public safety is found to arise—comment on the matter.

2. To find a “cause” of death in any given case, a coroner is required to consider what physiologically produced that result. Separately, a finding as to the “manner” of death involves a consideration of the circumstances in which the death took place. How broadly a coroner can, within jurisdiction, consider those circumstances is to be determined according to the relevant principles and the facts of each case.[2] Issues concerning the scope of this inquest are addressed below.

   [2] See generally R v Doogan; Ex parte Lucas-Smith [2005] ACTSC 74.

THE INVESTIGATION

1. For the purposes of the Act, an “inquest” means, in the first instance, an investigation.

The Autopsy

1. At my direction, Professor Johan Duflou, forensic pathologist, conducted a post-mortem examination. His opinion was that Rozalia died of myocarditis. The signs of the disease were not pronounced. The clinical manifestations of the condition were more severe than the apparent histologic changes in the heart. Histological samples were tested overseas in Hong Kong. Positive results for influenza A were obtained from samples taken from the throat, but not from the heart.

2. In his post-mortem report, Professor Duflou expressed his opinions in these terms:

   The clinical changes in the patient in the time leading up to death appear to be highly indicative of myocarditis, and a positive nasal swab influenza A PCR test provides support for a diagnosis of influenza A myocarditis. However, it is also the case that influenza A was not detected using both PCR testing and immunostaining on heart tissue sampled at postmortem, and the microscopic changes in the heart were similarly not typical of fulminant myocarditis.

   Given the conflicting virology results, the causative agent for the myocarditis has not been identified with certainty. Very likely, the myocarditis is viral or post-viral in aetiology, and it remains possible that the aetiological agent is the influenza A virus. On that basis, I give the cause of death as myocarditis.

Evidence from Treating Clinicians and the Relevant Medical Records

1. Relevant medical records were obtained by the Court, as well as statements from the practitioners involved in Rozalia’s care. Statements from the clinicians who treated Rozalia at TCH were obtained either through the ACT Government Solicitor (“ACTGS”) or the solicitors engaged by particular clinicians.

Expert Evidence

1. Expert opinions were sought to assess:

   (a)the course of Rozalia’s treatment (before and during her admission); and

   (b)the adequacy of the care provided to her at TCH.

1. The experts who provided opinions were:

   (a)Dr Robert Day, Senior Staff Specialist in Emergency Medicine, who practises at Royal North Shore Hospital in Sydney;

   (b)Associate Professor Mike Starr, Consultant Paediatrician, Infectious Diseases Physician and Consultant in Emergency Medicine at the Royal Children’s Hospital Melbourne, and Honorary Clinical Associate Professor at the University of Melbourne; and

   (c)Dr Marino Festa, Paediatric Intensive Care Physician, Medical Co-Director at the Paediatric Intensive Care Unit at the Westmead Children’s Hospital.

1. The opinions obtained from these experts informed the scope of the coronial investigation. The experts gave their evidence at the hearing concurrently. They presented their opinions as to the course of Rozalia’s care in an insightful and accessible way. For that reason, their opinions are quoted at length in the passages that follow.

The Appointment of Counsel Assisting

1. In inquests that do not involve deaths in care or custody, section 39 of the Act grants a coroner the discretion to appoint a lawyer to assist them in the inquest. As s 39A(1) of the Act provides, the role of counsel assisting is to provide assistance to the coroner in the inquest and to appear at the hearing. On 6 February 2023, I appointed Mr Michael Fordham SC as counsel assisting.

THE HEARING

1. As s 34 of the Act provides, in the ACT, a coroner conducting an inquest may conduct a hearing. In Rozalia’s case, it was my view that the evidence available to me in the form of statements and medical records did not fully address the manner and cause of her death, and that it was in the public interest that the evidence going to those issues be explored in a public hearing.

2. Nine days of hearing were conducted between 25 and 31 October 2023, and 4 and 7 December 2023.

The Scope of the Hearing

1. In addition to making the findings required by s 52 of the Act, I am also required by s 3BA(2)(a)(i) of the Act to carry out the objects of the Act in a way that recognises that the family and friends of the deceased person have an interest in having all reasonable questions about the circumstances of the person’s death answered. That responsibility, however, does not set aside the limitations s 52 of the Act places on my power to investigate.

2. On 11 August 2023, the Court sent an “issues list” to the interested parties. The purpose of that list was not to bind the Court as to the findings that should be made in light of the totality of the evidence, but to outline the focus of the matters to be explored at the hearing. I determined that those issues fell within an appropriate consideration of the manner and cause of Rozalia’s death and canvassed any public safety issues arising from that consideration. Those issues were:

   (1)The chronology of Rozalia’s presentation, condition, and deterioration.

   (2)The medical examinations, investigations, and treatment of Rozalia, including:

   (a)when examinations, investigations, and treatments were performed or provided;

   (b)the results of the examinations and investigations, and the effects of the treatments;

   (c)whether earlier or different investigation and/or treatments were indicated;

   (d)whether earlier transfer was indicated; and

   (e)what effect would earlier and/or different treatment and/or transfer have had?

   (3)The systems for:

   (a)the reporting of pathology results in the emergency department, paediatric emergency department and resuscitation areas; and

   (b)the allocation and handover of patients/beds/areas between responsible clinicians and nurses in the emergency department, paediatric emergency department and resuscitation areas.

   (4)The availability of paediatric services in the emergency department and paediatric emergency department at the Canberra Hospital, including paediatric cardiac and intensive care services.

   (5)The outcome of any reviews into paediatric services at the Canberra Hospital, so far as they related to the emergency department, paediatric emergency department, paediatric cardiac and paediatric intensive care services, and the implementation of any recommendations arising from those reviews.

   (6)Changes, if any, implemented at The Canberra Hospital since Rozalia’s death to:

   (a)systems for reporting pathology results in the emergency department, paediatric emergency department and resuscitation  areas;

   (b)systems for patient/bed handover/allocation in the emergency department, paediatric emergency department and resuscitation areas;

   (c)the provision of paediatric services in the emergency department and paediatric emergency department at the Canberra Hospital including paediatric cardiac and intensive care services.

The Parties

1. Leave was granted to a number of persons, who, in my view, had a sufficient interest in the present inquest, to be represented by a lawyer at the hearing and to examine or cross-examine witnesses. Pursuant to that leave,

   ·Mr Dan Shillington appeared for Rozalia’s family;

   ·Ms Maria Gerace SC and Ms Emily Aitken appeared for the Australian Capital Territory and the Canberra Health Services;

   ·Ms Jackie Sandford appeared on behalf of Dr Anne Mitchell;

   ·Mr Joshua Nottle appeared on behalf of Dr Khaleda Yesmin and Dr Kirsty Dunn;

   ·Mr Harry McCay (solicitor) appeared on behalf of Dr Mitchell Wilcox, Dr Aidan Watters, and Dr Conan Hall;

   ·Ms Teni Berberian appeared on behalf of Dr Jade Stewart;

   ·Ms Katrina Musgrove appeared on behalf of RN Lucinda Reumer; and

   ·Mr Karl Pattenden on behalf of RN Sarah Retford and Dr Abinesh Dhital.

PART 3 – ROZALIA’S GENERAL HEALTH

1. The course of Rozalia’s treatment at TCH must be placed in the context of her health history.

2. Counsel Assisting asked Katrina some questions about Rozalia’s health history:

   [I am going] to ask you a couple of questions about Rozalia's health, so how was her health in the years leading up to 2022?---She was perfect – perfectly healthy little girl. Had the odd – I think she had gastro probably once or twice. Other than that she would get little ear infections from time to time. On the last occasion she did get her last – second last ear infection the doctor noticed that her tonsils were rather large so he wrote up a referral letter to see Dr Makeham to see if we needed to get those removed. I did get a second opinion with my normal GP, Dr Serafim, and he confirmed that that, you know, would be a good recommendation. So, I went ahead and made that appointment but other than that, she was a normal, healthy young girl.

   Were all her immunisations up to date?---Yes, they were.

   You may have heard me say something in the opening about Fluvax?---M'mm.

   And by no means of criticism, but had she had a Fluvax?---No, she hadn't.

3. As with many young children, Rozalia had instances of an ear infection. She was otherwise a healthy child. Her parents were conscientious about her medical care when she became ill. She was fully immunised, though not vaccinated for influenza.

PART 4 – MYOCARDITIS (FULMINANT MYOCARDITIS)

PREVALENCE

1. To understand the course of Rozalia’s treatment, it is necessary to understand what myocarditis is. Myocarditis is rare. Associate Professor Starr gave this explanation of myocarditis, which was adopted by the other experts:

   Myocarditis… is inflammation of the muscle of the heart and that can occur by various mechanisms, and I guess the most common is what we call idiopathic. We don't exactly know what the cause is but we assume in many cases that it's caused by a virus. There's also concept of post infectious myocarditis which is where an infection such as influenza sets up an immune response and there's an immune mediated inflammation in the heart muscles. One way or another, it's inflammation of the heart muscle.

2. As to its relationship with influenza A, he added:

   So myocarditis can be caused… directly by influenza, so just as – and people will be aware of having the flu and you – there's inflammation of various tissues in the body and that can include the heart and by direct infection by influenza of the heart muscle. But what is thought to be more common is that in the context of having had flu just at the time or recently, that the – there is an immune response set up in the body and that includes the heart and the heart – the muscle of the heart becomes inflamed as a post infectious immune response. We see that with a number of other infections.

3. Without dissent from his colleagues, Dr Day also noted that myocarditis is a very rare complication of influenza and is rarely seen by clinicians, except for those who work in an ED setting. Associate Professor Starr’s opinion was that many adult physicians and paediatricians “would go through their careers without seeing it”.[3]

   [3] A/Prof Starr, T528.23.

4. Dr Festa noted that the severity of myocarditis is variable.[4] In Rozalia’s case, the experts agreed that the myocarditis seen was “fulminant”, which is a form of myocarditis that is “progressive and rapidly life-threatening”, and it is even rarer than general myocarditis.[5] Associate Professor Starr added that influenza is one of the causes of severe fulminant myocarditis and is more common amongst young children.[6] He added that given heart failure is more common in adults than children, the list of diagnoses that will cause heart failure in children is “much smaller”, and “a viral cause will be higher on the list”.[7]

DIAGNOSIS

[4] Dr Festa, T528.27.

[5] Dr Festa, T528. 29.

[6] A/Prof Starr, T528.44.

[7] A/Prof Starr, T529-530.

1. As to the diagnosis of myocarditis, the experts painted this picture:

   Probably the most salient sign is rapid heart rate, particularly if the heartbeat is not regular or there's something in terms of an arrhythmia, an abnormality of the heart rhythm. Congestion of the circulation with low blood pressure… The congestion aspect is an increase in the pressure in the veins returning blood to the heart, which manifests in different ways and can be quite subtle and difficult to pick up in children more so than in adults, who tend to be very compliant with clinical examination… One of the signs we do see is engorgement of the liver, which then is able to be felt outside of the rib cage and into the abdomen on examination, on direct palpation. It's not to say, however, that every cause of an enlarged liver is due to heart failure or cardiogenic shock, because it's definitely not.[8]

   [8] Dr Festa, T530.8-22.

2. If the heart failure was seated on the left side, it is likely to manifest in breathlessness. If seated on the right-side, swelling of the liver or legs will be apparent, because of “the impaired venous circulation back to the heart”. If the failure is general, then both presentations will be manifested.[9]

   [9] Dr Day, T530.25-35.

3. According to the experts, the diagnosis starts with a carefully taken history and an assessment of physical presentation:

   [Diagnosis], starts with a careful history, and you might look and ask specifically about, if you're suspicious of myocarditis – about any palpitations or feeling of butterflies in the chest, for example. The history of lethargy and not having energy is important. Often there's a loss of appetite, and sometimes there's some gastrointestinal symptoms like vomiting or cramping or pain in the abdomen, because the gut is deprived of blood flow.

   …

   There are signs. We have mentioned the rapid heart rate. We might pick up an irregular pulse. We might feel an engorged liver. We might feel the quality of the pulses in the wrist or even the feet is – very difficult to feel the pulse, and they're termed as thready. The patient will often look pale and they might feel clammy. The blood pressure itself is often diminished in terms of the two components of the blood pressure. The systolic is often low, but one thing that we do see if we're carefully looking is that the difference between the top number and the bottom number, which we term the pulse pressure, is also somewhat narrowed in the worst cases, when there's significant left ventricular dysfunction in particular. So there are a number of signs.[10]

   [10] Dr Festa, T532.20-40.

4. The fact that influenza A is present is a diagnostic indicator of itself, but it is only a starting point.[11]

   [11] A/Prof Starr, T532.12-19.

5. As to diagnostic tests, the “gold standard” is a myocardial biopsy, which is rarely done because it is very invasive.[12]

   [12] A/Prof Starr, T531.45.

6. An ECG is an essential and routine part of the early investigative process for anyone with a suspected heart problem.[13] As Associate Professor Starr explained, an ECG is a test of the electrical pulse through the heart. That electrical pulse can be affected by various things, including a lack of oxygen to the heart and an inflammation of the heart muscle or the lining of the heart (pericarditis).

   [13] Dr Day, T531.20.

7. A troponin test was also identified as an important diagnostic tool. Elevated troponin levels can be an indicator of damage to the muscles of the heart. Dr Day explained that in this way:

   So troponin is a protein that's released by damaged heart muscle cells and it's – the most common time we'd see it in an emergency department is in adults who had a heart attack, that – so it's something that's very commonly measured in the emergency department, and doctors working in a mixed emergency department seeing adults are very familiar with the – with ordering troponins and interpretation of troponins. It's much less frequently ordered in the paediatric age group, but occasionally, as in this case, there are indications for it. [The troponin level] varies depending on the – on the test, but – and each laboratory will have its own particular range, but often the – a normal troponin, for instance, would be less than 14. So a troponin of 1,600 or thereabouts is a – is definitely abnormal troponin.

   Mr Fordham SC: In this case, it was 1,295. I take it that remains definitely abnormal.

   Dr Day: Yes.[14]

   [14] A/Prof Starr, T533-534.

8. Associate Professor Starr explained the aggregation of those diagnostic factors in the following terms:

   For all of the thousands of cases we see, we rarely see myocarditis. But if you've got a positive influenza test and you've got an engorged liver and low blood pressure, and then an abnormal ECG, you think to do a troponin, that test of the protein from the heart, and if that was elevated, you've got your diagnosis confirmed.

TREATMENT

1. As to the treatment of myocarditis, Dr Festa gave a summary that was accepted by the other experts:

   So initially, the treatment is mainly supportive… to help the heart pump as efficiently as it can to reduce the amount of work the heart muscle has to do. If you think of it like a muscle that's getting – is inflamed and injured and, therefore, not able to pump and maintain the effort in the normal way of doing the work of pushing the blood around the body, then, you know, we have to nurse a fatigued, injured heart through the phase to recovery. And so many of the things we do just enable the heart to squeeze as well as it can, make sure that the heart is full enough with blood but not too full, and allow the blood to move forward into circulation that accepts the flow.

   And we control heart rhythm. We use drugs that we call inotropes which are directly affecting the squeezing potential and the capability and the strength of the squeeze of the heart muscle to assist the heart to pump adequately, but we don't force too much work onto the heart because it's already fatigued and can't take too much work. So just enough flow around the body to maintain adequate delivery of oxygen to all the parts of the body that need it, and we judge that carefully in the intensive care unit.

   There are some direct therapies that are used for which there is a limited evidence base… steroids and immunoglobulins are definitely used to try and modulate the immune response, particularly in infectious causes of myocarditis. But as I think we've illustrated, the diagnosis is made carefully but the absolute cause isn't always apparent. A lot of the case(s) are idiopathic, like, we don't know the cause. So it's very difficult to know with certainty how best to address the underlying pathology or problem that the body's having that's causing the inflammation.

   The final thing is, in patients that have the more fulminant course that we described earlier, a rapidly deteriorating course, unresponsive to treatments like inotropes and support with a ventilator… then we have the option in some cases to utilise mechanical support to take over the work of the heart,[15] and pump the blood around the body for the patient rather than relying on the heart to do that work, and that buys us a window for recovery or potential recovery.

   None of these therapies guarantee a recovery. I think that's an important point. It really depends on the – the natural course of that particular person's illness and the direction that will take, and the degree of injury to the heart itself, and to other parts of the body that may or may not have been deprived of blood flow as to what final outcome we'd get, even with the extra corporeal membrane oxygenation support we might be able to use in some cases.

   Mr Fordham SC: Is that otherwise known as ECMO?

   Dr Festa: It is, yes.[16]  [Emphasis added]

   [15] In these reasons, this is referred to as ECMO (extracorporeal membrane oxygenation) which is a modified prolonged cardiopulmonary bypass to support gas exchange, which allows the lungs to rest and recover (Oxford Concise Medical Dictionary). At the time of Rozalia’s death, ECMO was available at Westmead Children’s Hospital in Sydney. There was ad hoc availability of mobile ECMO outside of Sydney, including at Canberra Hospital. See Dr Festa, T592.39-43.

   [16] Dr Festa, T534.14-535.15.

2. As to the administration of fluids when myocarditis is suspected, Associate Professor Starr summarised the view of the experts:

   Well, the administration of fluid is always indicated. Children need to have fluid, obviously, and if they are sick, they are often dehydrated so they need some fluid, but fluid needs to be given with caution because the heart pump isn't… working. If you put fluid in, it can't be pumped around, and so… we need to give fluid [and] inotropes, medicines that help the heart pump instead of giving fluid, as well as giving smaller amounts of fluid.

   So you certainly give fluid. In fact, when a child's very sick, we might give what we call a bolus of fluid. You give a large amount of fluid to try to support the blood – the circulation as done with – in this case, and was appropriate initially, but you can't keep doing that if the heart's not pumping properly. You need to stop giving a whole lot of fluid and you need to give something to help the pump.[17]

PART 5 – THE STRUCTURE OF ROZALIA’S CARE ARRANGEMENTS AT TCH

[17] A/Prof Starr, T535-536.

1. The question of who had overall responsibility for Rozalia’s care after she presented at TCH and whether clinical staff responsible for her care were appropriately qualified in paediatric medicine were issues central at the hearing.

2. Whilst witnesses spoke of Rozalia’s care as being shared across clinicians and departments within TCH, as the analysis below highlights, that process did not always operate in a way that optimised clinical and diagnostic outcomes.

ED AND PAEDIATRIC ED

1. Whilst waiting to be assessed in the Emergency Department (ED), Rozalia was not formally admitted to the hospital. However, she was in the care of the ED. There were clinicians in the ED who were assigned responsibility for paediatric cases, and paediatric cases were generally accommodated in a separate area of the ED. Whilst the ED’s paediatric space was not operational on all shifts, it was operational during Rozalia’s admission. Clinicians attached to the care of paediatric cases in the ED did not necessarily have paediatric specialisation in their training.

2. It was open for a paediatric patient being assessed and treated in the ED to be admitted under the care of a paediatrician consultant if a doctor considered a longer stay in hospital was needed. This occurred in Rozalia’s case, when she was admitted to TCH Paediatrics under the care of Dr Anne Mitchell, the on-call Paediatric Consultant. This occurred at around 0530 hours on 5 July 2022.

3. Two ED doctors were to play central roles in the early stages of Rozalia’s care after her presentation to the ED.

Dr Tze Hao Wong

1. At the time of Rozalia’s presentation, Dr Wong was working as an Emergency Registrar in the ED. He had been in that role for approximately one year. He had been working at TCH for close to 5 years as a Senior Resident Medical Officer, Resident Medical Officer, and Intern. He was working the night shift in the Paediatric ED and started work at 2230 hours on 4 July 2022. At the time, although Dr Wong was assigned to the Paediatric ED, he had no specific training in paediatrics.[18] Dr Wong’s CV does not refer to paediatric experience of any kind. In evidence, he indicated that he had not received any paediatric training in his education as a doctor.[19]

   [18] T70.5-9.

   [19] T70.8.

2. On 5 July 2022, Dr Wong was the only doctor on duty overnight in the Paediatric ED. Whilst he received a handover for the patients in the Paediatric ED, he was not handed over information about Rozalia, as she had not been seen by a doctor by that point.

Dr Kate Watson

1. At the time of Rozalia’s presentation, Dr Watson was employed by CHS as a Senior Registrar in the ED. She had a background by training and experience in Emergency Medicine and had been a Senior Registrar at TCH since February 2018. Dr Watson did not have specific paediatric training or experience.

2. On 4 July 2022, she commenced her shift at 2230 hours. As the Night Shift Registrar, Dr Watson’s role was to oversee staff and patients in the whole of the ED, including the Paediatric ED. She described the primary focus of her role was to review patients in the acute (resuscitation) area of the ED, to attend (as requested) to care issues arising in relation to other ED patients, and to provide guidance to other ED doctors.[20]

   [20] Statement of Dr Watson, Exhibit 1, 504.

PAEDIATRICS

1. There was also a general paediatric ward at TCH, which was physically separate to the ED. Children could be admitted to that ward through different channels, including from other areas within TCH (such as the ED or the ICU). Staff members of the general paediatric ward provided care directly to the children in the paediatric ward. Paediatric patients could also be admitted under the care of paediatric consultants, but remain physically located in other areas of TCH (such as the ED or the ICU). Paediatrics staff also provided expertise which could be drawn on by other areas of the hospital (such as the ED or the ICU).

2. Rozalia remained physically in the ED, rather than being transferred to the general paediatric ward, because a bed in the general ward was not available[21], and, in any event, the acuity of her condition justified a level of care appropriately delivered in an ED setting, and diagnostic issues were thought to be better addressed in an ED setting.

   [21] Statement of Dr Mitchell, Exhibit 1, 585[20].

3. In Rozalia’s case, it was not always clear where the ultimate responsibility for clinical decision-making lay. The Australasian College for Emergency Medicine provides this guidance:

   At the point where an admission decision is made, handover of primary responsibility for care to another specialty service will occur, and a patient will depart the ED. Where a patient remains in ED pending transfer to an inpatient bed, the responsibility for clinical care is shared with the other specialty service (the ‘admitting team’). The non-EM specialty service is responsible for ongoing definitive management plans, full medication review and reconciliation, specialist care and planning of non-ED procedures and investigations.

   While ED teams will assist in co-ordination where possible, the ED remains responsible only for primary management (assessment, commencement of initial therapies, documentation of interim medication, fluid, and clinical management orders so that a patient will receive appropriate care until inpatient team review) and ongoing immediate response to unanticipated sudden deterioration, where the ED team will provide immediate stabilization until the inpatient team can respond.[22]

   [22] Australasian College for Emergency Medicine, Responsibility for care in emergency departments (Policy Guideline, March 2024) 4-5.

4. Dr Day analysed care arrangements where paediatric cases were admitted to an ED in the following terms:

   Yes. So it's an extremely common occurrence in emergency departments, and it's probably more the rule than not that patients, after they have been admitted under a specialty, remain in the emergency department, and sometimes for many hours, and so every hospital has to have a system as to who is actually responsible for that patient. It's always going to be a shared care model because they're in the emergency department, but they're admitted, in this case, under a paediatrician. So both teams have some responsibility, but it's – at a hospital level, it needs to be decided who is responsible for what, and I agree with Associate Professor Starr that the patient is in the emergency department, so the emergency department still has primary responsibility for the patient, and that means that a doctor is actually allocated to that patient, including if there's a handover and one – the doctor who was initially looking after that patient leaves; another doctor has to have – be responsible for the patient in the emergency department. That said, the paediatric team also has responsibility for the patient, and often that is to do with their sort of major management decisions and ongoing care, and certainly it would be essential that if there's a change in condition of a patient in the emergency department, who is admitted under a team, that that team is informed so that they can review the patient.[23]

   [23] Dr Day, T553-554

1. Two paediatric doctors were central to the chronology of Rozalia’s care in the early times of her care at TCH.

Dr Callum Jarvis

1. Dr Jarvis was working the night shift at TCH, commencing at 2130 hours on 4 July 2022 and finishing at 0830 hours the next morning. He was working at TCH as a locum General Paediatric Registrar. At the time of completing his statement on 30 March 2023, he was a second-year Royal Australian College of Physicians Advanced Trainee in general paediatrics, having worked in paediatric roles since 2017. At the time of Rozalia’s admission to the ED, Dr Jarvis’ role included caring for all children currently admitted to the paediatric wards at TCH (excluding Women’s Health, Special Care Nursery and Neonatal Intensive Care Unit). He was asked initially to review Rozalia in the ED by Dr Wong, the ED doctor on duty at the time.

Dr Anne Mitchell

1. Dr Mitchell was a Senior Specialist Paediatrician. Dr Mitchell graduated with a Bachelor of Medicine and Bachelor of Surgery in the United Kingdom in 1986 and obtained her fellowship of the Royal Australian College of Physicians in 1999. She worked at TCH from 2014 to 2022.

2. On 4 July 2022, Dr Mitchell was the on-call paediatrician. Her on-call shift commenced at 0800 hours on 4 July 2022 and ended at 1200 hours on 9 July 2022. She was available to provide advice to the most senior doctors on duty.[24]

   [24] Statement of Dr Mitchell, Exhibit 1, 583[6].

3. Rozalia was formally admitted under Dr Mitchell’s care, under what Dr Mitchell called her “bed card”.

INTENSIVE CARE UNIT (“ICU”)

1. The ICU provides critical care at TCH, including life support and advice to other clinicians, who are, for example, considering transferring a patient to the ICU or who may be assisted by the specialised knowledge of an ICU clinician.

2. There was no paediatric ICU at TCH at the time of Rozalia’s admission.

3. Two ICU doctors were important in the early phases of Rozalia’s care.

Dr Conan Hall

1. At the time of Rozalia’s admission, Dr Hall was a doctor in the ICU. He was in his fourth year post graduation. In that period, he had specialised in Critical Care. He indicated in his statement that the ICU is primarily “an adult ICU” and “we have very few paediatric admissions and reviews”.[25] Dr Hall was on shift commencing at 0730 hours on 4 July 2022 and ending at 0830 hours on 5 July 2022. He was the “Outreach Registrar”, whose role involved taking referrals and reviews for potential admissions and seeing those patients to consider whether, in consultation with the Senior Registrar and ICU Consultant, they should be admitted to the ICU.[26] The Outreach Registrar also attended MET calls across the whole hospital.

Dr Abinesh Dhital

[25] Statement of Dr Hall, Exhibit 11.6, 1.

[26] Ibid.

1. At the time of Rozalia’s admission, Dr Dhital was a Senior Registrar in the ICU. He had been working in the ICU since 2021.[27] He qualified overseas, and his early experience included work in a surgical setting. His recent experience included working as an anaesthesiologist in NSW hospitals, and he had specialised in Emergency Medicine and Intensive Care during his time at TCH. He started his shift at 1930 hours on 4 July 2022 and was due to finish at 0830 hours the next day. On 5 July 2022, he had responsibilities for patients within the ICU and performed tasks associated with the ICU’s outreach function. In his statement, he noted that there was no paediatric ICU at TCH, and that the ICU “has not usually admitted paediatric patients except in limited circumstances”. He also stated, “I am not fully trained to look after very sick children in the ICU, as it is a separate sub-speciality of intensive care training”. He went on to say, “whenever children are admitted to the ICU at TCH, their diagnosis and their treatment is managed (overseen) by the admitting specialist (paediatrics) from outside the ICU”.[28]

ACCESS TO SPECIALISED PAEDIATRIC SERVICES IN NSW

[27] Statement of Dr Dhital, Exhibit 11.11, 1.

[28] Ibid 2.

1. In the later stages of Rozalia’s care at TCH, treating clinicians were able to draw on the advice of specialised paediatric clinicians from the Westmead Children’s Hospital in Sydney and to plan her transfer to Westmead. The Newborn and Paediatric Emergency Transport Service (“NETS”) is an emergency service for sick or injured babies, infants, and children needing a transfer to one of the two specialist perinatal or paediatric hospitals in Sydney or John Hunter Hospital in Newcastle.

2. The service operates in NSW and the ACT. It has its own medical staff and a clinical co-ordination centre that enables retrieval specialists to give advice and engage in discussions with clinicians, including those at TCH, in respect of critically ill children who may need to be transferred to Sydney. The retrieval service operated by NETS enabled critically ill children, such as Rozalia, to be taken by helicopter to facilities in Sydney, including the Sydney Children’s Hospital at Randwick and Westmead Children’s Hospital, which have the clinical specialisations and equipment, including ECMO, to provide appropriate treatment in any such cases.

PART 6 – TRIAGING & ONGOING ASSESSMENT IN ED

1. Triaging is a process by which patients are treated in an order that reflects the acuity of their presenting condition when that acuity is time critical. The Guidelines on the Implementation of the Australasian Triage Scale in Emergency Departments (“the Guidelines”) provides this summary of the triaging process:

   Triage is the first point of public contact with the ED. The triage assessment generally should take no more than two to five minutes with a balanced aim of speed and thoroughness being the essence. The triage assessment involves a combination of the presenting problem and general appearance of the patient, and may be combined with pertinent physiological observations. Vital signs should only be measured at triage if required to estimate urgency, or if time permits.

2. Under the guidelines, there are triage categories number 1 to 5, the applicable response times in respect of each category, a description of each category, and various indicative clinical descriptors. The category requiring an immediate medical response is Category 1. Relevant to Rozalia’s case were Categories 2 and 3.

3. Under the guidelines, Category 2 applies to patients whose condition is imminently life-threatening, or who require important time critical treatment or is in very severe pain. The indicative clinical descriptors for this category include “fever with signs of lethargy (any age)”. The response to someone assessed as Category 2 is assessment and treatment within 10 minutes.

4. Category 3 applies to patients whose conditions are potentially life-threatening, where there is potential for adverse outcome if time critical treatment is not commenced within 30 minutes or where “humane practice” mandates relief of severe discomfort or distress within 30 minutes. The indicative clinical descriptors for this category include “severe hypotension”, “persistent vomiting”, and “dehydration”. The response to someone assessed as Category 3 is assessment and treatment within 30 minutes.

5. If a patient’s condition changes whilst waiting for the treatment, or if additional relevant information that impacts on the patient’s urgency becomes available, the patient should be re-triaged.[29]

   [29] Guidelines on the Implementation of the Australasian Triage Scale in Emergency Departments, Exhibit 1, 2532-2539.

6. Whilst waiting in the ED, nursing staff conduct observations of those awaiting assessment. In respect of paediatric cases, those observations form part of the Paediatric Emergency Warning Scale (PEWS) patient care record. The PEWS system used at TCH is a grading system designed to identify risks for clinical deterioration in paediatric patients. PEWS is made up of eight components, which are measured on a scale of 0 to 4 to create a score. The individual components recorded include observations of respiratory rate, heart rate, blood pressure, and temperature. An individual score of 4 requires an urgent response. The overall score also dictates the process and timing of escalation.

SAFETY NET PROCESSES WHEN TRIAGE RESPONSE TIMES NOT MET

1. Evidence given at the hearing indicated that whilst the health records system in place at the time had the capacity to notify or alert staff if patients were not seen within the time specified by the triage guidelines, those working on triage were generally too busy to follow up on any such alert or notification.[30] It is assumed that if alerts were raised on the night of Rozalia’s presentation at ED, staffing pressures caused them to be ignored.

   [30] T351.1-5; 352.1-25.

2. As of 4 July 2022, TCH had the position of a Clinical Initiatives Nurse (CIN) performing the roles similar to those described by the experts as being in place at other hospitals. The evidence did not reach the level of explaining, as a matter of job description, what the position actually entailed at TCH. The position was filled on the night of 4 July 2022, but only to 2130 hours. The evidence did not explain why the failure to adhere to the 30-minute response time did not result in any follow-up actions before the CIN finished their shift.

3. It is assumed that the CIN role at TCH followed the model that is adopted in other jurisdictions. The experts gave evidence of systems for the monitoring and reassessment of patients after triage and whilst in the waiting areas of the EDs of the hospitals at which they work. They were variously described as involving a CIN to keep observations in the waiting room, to be alert to deteriorating patients, and to perform tests like ECGs and blood tests and repeating observations. Dr Day also spoke of a role for a lay person, who primarily assists with wayfinding and directions, but can be approached by patients or parents if they are concerned about deterioration. Such processes exist at the Royal North Shore Hospital (and most EDs in NSW)[31] and the Westmead Children’s Hospital.[32] Associate Professor Starr gave evidence of a rapid team at the Royal Children’s Hospital in Melbourne, which consists of a consultant, a Registrar or Resident, and a nurse who would commence management and reassess.[33]

PART 7 – THE STAGES OF ROZALIA’S CARE

STAGE 1 – TREATMENT OF ROZALIA’S CONDITION BEFORE PRESENTING AT TCH

[31] T546.36-547.7.

[32] T547.30-37.

[33] T546.23-30.

1. On 28 June 2022, Rozalia went to the Kingston Foreshore Medical Centre with her mother and was seen by Dr Khaleda Yesmin. She presented with a fever and headache and was diagnosed with an ear infection. Her temperature was normal, but her eardrums were inflamed. She was prescribed antibiotics.[34] Her mother’s impression was that her condition improved. She appeared to have recovered by 2 July 2022.[35]

   [34] Exhibit 1, 169-170. See also T51.35-40.

   [35] Statement of Katrina Spadafora, Exhibit 1, 924[252].

2. On 3 July 2022, Rozalia was lethargic, not her normal self, and unable to participate fully in her birthday party.[36] She was taken by her mother to the Canberra After-Hours Locum Medical Service on the evening of 3 July 2022, where she was seen by Dr Khaleda Edib and was prescribed an oral corticosteroid for a dry cough. Dr Edib made a differential diagnosis of a viral illness.[37] Her mother was told to continue with the antibiotics and to seek further advice if her condition worsened.

   [36] T22.23.

   [37] Exhibit 1,172. See also Statement of Dr Edib, Exhibit 1, 178-179, 180-181.

3. Overnight on 3 and 4 July 2022, Rozalia developed pallor, puffiness, a poor appetite, and lethargy, which appeared to have worsened.[38] Consistent with the advice given by Dr Edib, Rozalia’s mother took her back to Dr Yesmin at the Kingston Foreshore Medical Centre on 4 July 2022. She was found to have a low-grade fever and tachycardia (that is, an elevated heart rate). She was described by her mother and the doctor as being unwell and unable to stand. Dr Yesmin described Rozalia as “refusing to walk”[39] and “unwell and refused to walk due to lethargy”.[40] Dr Yesmin sent Rozalia and her mother to the ED at TCH.[41] Dr Yesmin referred Rozalia to TCH not because she felt her condition was critical, but because she felt that Rozalia needed further testing, and it was likely that it would be done more quickly if she was in a hospital setting.[42]

   [38] Katrina Spadafora, T23.

   [39] Statement of Dr Yesmin, Exhibit 1, 169.

   [40] Supplementary statement of Dr Yesmin, Exhibit 1, 171. See also TCH Clinical Notes - Kingston Foreshore Medical Centre, Exhibit 1, 162; and Katrina Spadafora T22.35-45.

   [41] Exhibit 1, 161-162. See also Exhibit 1, 169-171.

   [42] T59.5-10. See also Katrina Spadafora T24.25-35.

4. Dr Yesmin did not provide a referral letter, nor did she phone the hospital to advise that Rozalia would be arriving. Dr Yesmin said that she could have written a letter to set out her concerns,[43] and that it would probably have been helpful to inform the hospital of what she wanted and why she wanted it done.[44] However, in the end, she thought it would not have made a difference, as Rozalia would be triaged at TCH in any event.[45] She said that she assumed Rozalia would be triaged promptly.[46]

   [43] T57.17-18.

   [44] T58.18-20.

   [45] T58.2-4.

   [46] T 61.20-25.

5. Although not explored in any detail in the evidence, there was a reference to an email system known as “HealthLink”,[47] which is available to community clinicians referring patients to TCH. However, Dr Yesmin indicated that she was not aware of the CHS’ general advice that GPs sending letters to the ED, either in advance, or with patients, was a good idea.[48]

Expert Review of Pre-TCH care

[47] T62.10-12.

[48] T60.5-10.

1. The experts made no criticism of the care provided by the GPs who were consulted.

2. The failure to send an accompanying letter was unlikely to have changed the course of events. The evidence of Dr Day was that whilst a referral letter from a GP is “very useful”,[49] he did not believe a letter or phone call would have changed the triage category or treatment given to Rozalia. [50] Associate Professor Starr noted that:

   not only does information from the GP or the community not replace the triage, but it doesn’t replace taking a clear history for one’s self and making your own assessment …[51]

STAGE 2 – ADMISSION TO TCH, TRIAGE AND TREATMENT UNTIL 0016 HOURS

[49] T582.5-9.

[50] Supplementary report of Dr Day, Exhibit 4, [9].

[51] T582.24-27.

1. Rozalia was taken to TCH by her mother. She arrived shortly after 1900 hours,[52] and was triaged in the ED at 1940 hours.[53]

   [52] Katrina Spadafora, T24.43.

   [53] TCH Clinical Notes, Exhibit 1, 223.

2. Katrina’s impression was that the ED did not seem very full. However, this did not reflect the reality for those working on the ground. On 4 July 2022, RN Manda De Ramos was undertaking, amongst other duties, triaging duties. Her evidence was that triage was busy on the evening of 4 July 2022,[54] and the statistical evidence provided by the Territory confirmed the accuracy of RN De Ramos’ impression.

   [54] T353.45-354.5.

3. When spoken to by nursing staff, Katrina outlined Rozalia’s medical history at some length, including that she had not been walking.[55] The nursing assessment relevantly recorded the following:

   “Child is not drinking and eating much. Child more lethargic.

   [55] T25-26.

4. Rozalia was triaged as a Category 3 patient, which should have had her seen by a medical officer within 30 minutes.[56] The experts regarded this triage categorisation as reasonable.

   [56] Expert report of Dr Day, Exhibit 1, 2523-2534, 2537.

5. However, Rozalia was not seen by a doctor until about 0016 hours the next day, almost 5 hours later.[57]

   [57] Statement of Dr Wong, Exhibit 1, 419-420[12]. See also Exhibit 1, 403.

1. In Rozalia’s case, observations were taken at the time of triage at 1940 hours. Rozalia’s temperature was recorded as 36.4°C, her pulse was 121, and her respiratory rate was 28.

2. Observations were taken again at 2155 hours. By that time, Rozalia’s temperature was 37.9°C, her heart rate was 139, and her respiratory rate was 38. Those results led to an overall PEWS score of 3.

3. Rozalia’s blood pressure was not taken on arrival at triage, notwithstanding the fact that blood pressure was part of the PEWS escalation matrix. At the hearing, views differed as to that practice:

   (a)RN De Ramos indicated that she seldom takes the blood pressure of a child;

   (b)Dr Jarvis was the Paediatric Registrar on duty that night. He commenced his shift several hours after Rozalia presented to the ED. He gave evidence that, in his view, a blood pressure reading should have been taken on admission, and that this is routine at a number of sites where he works;[58] and

   (c)The expert evidence was that it is not unusual for blood pressure not to be taken, due to the limited time available at triage and that it can be confronting and uncomfortable for a child to have blood pressure taken.[59]

   [58] T107.11-16.

   [59] T541.17-29.

4. Dr Jarvis was also of the view that blood pressure should have been taken at 2155 hours, given the change in the recorded observations.[60]

Experts Review of Blood Pressure Testing

[60] T108.15-17.

1. Even in the context of treatment delays in busy EDs, there are opportunities for triage categories to be changed and for priorities for treatment to be recalibrated. The experts agreed that it is trends in observations that are important.[61]

   [61] T544.10-17; T545.1-7.

2. Expert evidence suggested that blood pressure should have been taken at 2155 hours, based on the outcome of the other observations taken at the time.[62] If nothing else, it was relevant to a proper determination of the PEWS score.[63] The experts further considered that, in light of the observations recorded at 0420 hours the next day, and the fact that Rozalia’s blood pressure was low when first taken at that time, her blood pressure would likely have been similarly abnormal at 2155 hours, if it had been taken at that time.

   [62] T541.39-T542.27.

   [63] T544.7-8.

3. Had a low blood pressure been recorded at 2155 hours, that would have elevated the PEWS score to at least 4 and required notification to the Team Leader and a review by a Resident Medical Officer within 30 minutes.

4. Even without the blood pressure having been taken or factored into the PEWS assessment, the trending change in observations taken at 2155 hours and the length of time Rozalia had been waiting could reasonably have led to an escalation in the triage Category to 2, which should have had Rozalia seen by medical staff much earlier.[64]

STAGE 3 – FIRST REVIEW BY A DOCTOR AT 0016 HOURS TO HER SECOND REVIEW AT 0420 HOURS

[64] T544.20-37. See also expert report of Dr Day, Exhibit 1, 2524[48].

1. Dr Wong was the first doctor to review Rozalia at 0016 hours. He had no specific training in paediatric medicine.[65]

   [65] Dr Wong, T70. 6-8.

2. Prior to his assessment, Dr Wong had seen Rozalia in the waiting room prior to midnight. He described Rozalia as looking tired and “virally”, and that she “looked like a child who looked unwell with a viral infection”.[66] He pre-emptively ordered a trial of oral fluids. [67]

   [66] Statement of Dr Wong, Exhibit 1, 419[10].

   [67] T77.15-20.

3. On review at 0016 hours, Dr Wong considered that Rozalia was dehydrated. He recorded in his retrospective clinical note, written at about 0400 hours, that it was at a level of 5 to 10%.[68] He gave evidence that this was based on an assessment tool from the Royal Children’s Hospital.[69] On review of the assessment tool whilst giving evidence, Dr Wong said that the estimate should actually have been 5 to 9%.[70] This was described by Dr Wong as moderate dehydration.[71]

   [68] TCH Clinical Notes, Exhibit 1, 226.

   [69] T91.18.

   [70] T91.26.

   [71] T101.35-37.

4. Dr Wong’s clinical note does not record his observations with respect to a viral infection.[72] The plan, as recorded, was simply “paed’s review and bloods”. Whilst Dr Wong did have regard to the triage observations, he did not look at the general observations chart for observations recorded at 2155 hours prior to reviewing Rozalia at 0016 hours.[73]

   [72] TCH Clinical Notes, Exhibit 1, page 225.

   [73] T75.23-33.

1. Dr Wong was unable to recall the content of his conversation with the paediatric doctor he spoke with at 0200 hours, who, as it later became clear, was Dr Jarvis. He was uncertain as to whether he had told Dr Jarvis that he thought Rozalia most likely had a viral illness. Similarly, Dr Wong was unable to recall whether he had told Dr Jarvis about Rozalia’s vital signs.[74] Dr Jarvis did not recall having any discussions about Rozalia’s vital signs.[75] Dr Wong did not draw Dr Jarvis’s attention to what was recorded on the general observations chart,[76] which showed, in part, a deterioration in Rozalia’s condition from triage to the time of his review.

   [74] T83.26-27.

   [75] T106.45.

   [76] Exhibit 1, 286.

2. Whilst he did tell Dr Jarvis that Rozalia was tachycardic and tachypneic (that is, rapid breathing), it is likely Dr Wong did not inform Dr Jarvis, the Paediatric Registrar, of his suspicion of a viral illness or Rozalia’s vital signs.

3. Dr Wong did not consider taking Rozalia’s blood pressure.

4. Dr Wong ordered a change to IV rehydration, because Rozalia was vomiting. Consequently, there was a danger of aspiration with a nasogastric tube in place, and because he had to take bloods anyway (and therefore could insert a cannula which could also be used for rehydration).[77] Dr Wong also engaged with the paediatric team at around 0200 hours to refer Rozalia for further review.[78]

   [77] T102.10-16.

   [78] Exhibit 1, 422[22].

5. Dr Wong gave evidence of the difficulty he had in obtaining blood from Rozalia,[79] and that part of the reason to rehydrate her was to assist in obtaining blood.[80]

   [79] T83.28-31.

   [80] T84.9-16.

6. Intravenous fluids were commenced at 0410 hours, following Dr Wong’s review. There was an initial improvement in the acidosis and lactate levels following the delivery of fluids.[81] That did not continue.

Expert Review of Dr Wong’s Assessment

[81] In a dehydrated child, improvements in acidosis and lactate levels after IV fluids suggest that fluid replacement was helping to restore blood circulation, oxygen delivery, and blood pH balance.

1. The experts reviewed Dr Wong’s assessment. They agreed that it was reasonable to suspect a viral illness as the cause of Rozalia’s symptoms, although that suspicion was not recorded.[82] Dr Festa noted that whilst there was a level of concern and a plan to refer, due to the paucity of the notes, it was difficult to understand what Dr Wong’s thought processes might have been. There could have been any number of causes for Rozalia’s symptoms.[83] There was no mention of the observations done or their abnormality.[84] There was no differential diagnosis or any list of possible diagnoses;[85] “it’s very much about referring into the specialist team for further assessment and doing blood tests”.[86]

   [82] T548.44, 549.11, 549.17 and 549.29.

   [83] A/Prof Starr, T549.35.

   [84] Dr Day, T548.23.

   [85] T549.17-24.

   [86] Dr Festa, T549.24.

2. The experts agreed that blood pressure should have been taken at that point.[87] They agreed that not much had been done since the previous review at 2155 hours. A nasal swab that occurred just after 0400 hours could have been done earlier.[88]

   [87] T550.24-33.

   [88] Dr Day, T549.40.

STAGE 4 – FIRST PAEDIATRIC REVIEW AT 0420 HOURS TO THE END OF SHIFT AT 0830 HOURS

1. A number of treatment decisions that were made in this period were central to the course of Rozalia’s care.

2. Rozalia was reviewed by Dr Jarvis, the Paediatric Registrar, and Dr Kevin Tee, a Resident Medical Officer (RMO) at 0420 hours.

3. A venous blood gas result was available at 0345 hours. It revealed a lactate of 4.9,[89] which was consistent with poor perfusion.[90] Dr Jarvis took the first blood pressure measurement during his examination at 0420 hours. He recorded a blood pressure of either 71/41[91] or 71/54[92] – either reading was accepted to be low.[93] Dr Day described it as “significantly below normal”.[94] Tachycardia was present. Dr Jarvis found an enlarged liver.[95] He agreed that a cardiac cause for the enlarged liver should be considered in the presence of hypotension and tachycardia,[96] and it was that consideration that led to his request for an ECG between 0545 and 0550 hours.[97] The ECG took place at 0652 hours.[98] Dr Jarvis gave evidence as to his thinking in requesting the ECG:

   Thank you. Now, you mentioned before the ECG and the troponin?---Yes.

   Now, I just want to deal with those in order. Firstly, which of those two was considered first? Or were they considered together?---I had been considering doing the ECG with the ongoing heart rate, and then we – when I had a discussion with the emergency doctor, she suggested and I agreed that we should do a troponin test as well.

   All right. I'll deal with them in order. What was your thinking around the need to perform an ECG?---So the – the main thinking around an ECG is to look for in the – in this situation, things such as myocarditis or pericarditis or pericardial effusion, so the inflammation of various layers of the heart.

   And I think you said that the ED doctor – and I take it you mean the female senior registrar - suggested the troponin?---Yes. The troponin, yes.

   And what is the reasoning or why would you---? ---That's similar. That
   is---

   Sorry. Why would you test troponin?---The main reason in this instance is looking for myocarditis.[99]

Expert Review of Dr Jarvis’ Assessment

[89] TCH Clinical Notes, Exhibit 1, 233.

[90] Expert report of Dr Day, Exhibit 1, 2520[13].

[91] Statement of Dr Jarvis, Exhibit 1, 560[15(b)].

[92] TCH Clinical Notes, Exhibit 1, 286.

[93] T110.35-47.

[94] Expert report of Dr Day, Exhibit 1, 2520[17].

[95] T113.20-26.

[96] T113.27-30.

[97] Statement of Dr Jarvis, Exhibit 1, 561[22]-[24].

[98] TCH Clinical Notes, Exhibit 1, 283.

[99] T121.7-27.

1. Dr Festa said that the examination undertaken by Dr Jarvis was “thorough”,[100] and it was an “overall good and timely intervention that was required to try and understand better that Rozalia had a significant problem that needed more urgent attention than she’d previously got in the Department…” [101] However, in retrospect and knowing what Rozalia was suffering from, Dr Festa thought that the constellation of low blood pressure, rapid heart rate, and a large liver should have provoked an alternative diagnosis of a heart that was not able to work properly.[102] He did not suggest that that should have been “the first diagnosis”, but it was the “beginning of a constellation of signs that might point you to that way of thinking”.[103]

   [100] T552.19.

   [101] T552.21-24.

   [102] T552.37-39.

   [103] T552.40-43

2. Dr Day thought the assessment was good and that reasonable first steps were taken.[104]

Dr Jarvis and Dr Tee’s Second Review at 0530 Hours

[104] T553.11. The differential diagnosis of a heart-related issue is consistent with Dr Jarvis’ ordering of an ECG.

1. At about 0527 hours, Rozalia was moved to Resuscitation bed 2 in the ED.[105]

   [105] TCH Clinical Records, Exhibit 1, 401.

2. Rozalia was seen by Dr Jarvis and Dr Tee again at 0530 hours. By that time, blood tests that were available showed, amongst other things, a white blood cells count of 4.3, neutrophils of 2.52, and lymphocytes of 1.35.

3. The lactate had reduced from 4.9 to 3.9. Whilst the downward trend was good, the result of 3.9 was still very high.[106]

   [106] T555.25.

4. Dr Jarvis agreed that the white blood cells count and lymphocytes were consistent with an underlying viral infection,[107] and he commenced antibiotics in an effort to address potential sepsis.[108] After consulting with Dr Mitchell, he also requested an ICU review and noted that bloods/cultures test results were to be chased and urine was to be tested.

   [107] T114.30. See also expert report of Dr Day, Exhibit 1, 2520[18].

   [108] Statement of Dr Jarvis, Exhibit 1, 561[25].

5. Following the initial delivery of 190mL of intravenous fluids at 0400 hours, further fluid boluses of 190mL were delivered at 0430, 0520, and 0545 hours. 1000mL (at 110mL/hour) were initiated at 0640 hours. 200mL were delivered at 0730 hours.[109]

Experts Review of Dr Jarvis’ Clinical Decision Making

[109] TCH Clinical Records, Exhibit 1, 336.

1. Dr Day thought the plan to commence an IV broad spectrum antibiotic, to repeat a fluid bolus, and to seek ICU review was reasonable.[110] Dr Festa said that ICU needed to be asked if inotropic support was warranted.[111] Dr Festa gave evidence that, over the course of the morning of 5 July 2022, Rozalia eventually received more than 40mL/kg of fluid, which was in excess of what she required and may have caused some degree of harm.[112]

The Addition of Troponin and the First ICU Attendance

[110] T556.1-6.

[111] In oral evidence, Dr Festa referred to 20mL/kg of fluid as having been delivered (T557.7-1), however in his report he refers to 10mL/kg (see expert report of Dr Festa, Exhibit 1, 2635), which accords with Dr Day’s expert report, Exhibit 1, 2520[16].

[112] T583.5-15. See also expert report of Dr Festa, Exhibit 1, 2636[2].

1. At 0610 hours, Rozalia’s PEWS score was recorded as 6.[113]

   [113] TCH Clinical Records, Exhibit 1, 286.

1. Dr Kate Watson had a conversation with Dr Jarvis at approximately 0630 hours, during which she suggested the addition of troponin and creatine kinase to the blood tests that were being processed at the time.

2. Dr Watson gave evidence that she suggested the addition of a troponin test to exclude the potential of influenza myocarditis,[114] but that because it was a rare diagnosis, she was not expecting the test to come back as positive.[115] That request appeared to have been received in the TCH pathology laboratory at approximately 0644 hours.[116]

   [114] T299.12-14.

   [115] T303.6-11.

   [116] Exhibit 1, 393. See also T309.7-8.

3. Dr Watson’s expectation was that the result would be back within an hour, or an hour and a half.[117] Associate Professor Starr said that he would expect a troponin result within 60 minutes. Dr Day gave evidence that the benchmark was 60 minutes, and that he would expect the result within 90 minutes. Dr Festa said that he would be happy with 90 minutes.[118]

   [117] T307.8-11.

   [118] T570.7-18.

4. Dr Tee checked the system for the blood test results at 0552, 0556, 0558, 0612, 0644, and 0736 hours.[119]

   [119] Statement of Dr Tee, Exhibit 1, 575[19].

1. At the conclusion of his review at about 0530 hours, Dr Jarvis contacted Dr Mitchell, who was the Paediatric Consultant on duty. He called at about 0550 hours. His recollection of what he told Dr Mitchell was:

   So the – my – the purpose of the phone call was to relay my concerns and also to request that she review Rozalia. So the information I relayed was that she was – the history, the story that I got from the family that she was a 5-year-old girl, the story of the preceding week that I'd been given, as well as the clinical examination and then the – and investigations that I had available at the time. And I then asked that Dr Mitchell review the – review Rozalia, which she agreed to and probably did a review.

2. Amongst other things, Dr Mitchell requested that Dr Jarvis seek a review by the ICU.[120] Her reason for doing so was because although Rozalia had been administered “40mL/kg IV fluids”, she remained hypotensive and potentially required inotropic supports.[121] Inotropic therapy is used to modify the contractions of the heart in a way to increase blood pressure,[122] and it can be used when the administration of fluids has not sufficiently raised blood pressure or improved perfusion. In that way, the therapy can relieve pressure on the heart.

   [120] T123.26-28.

   [121] Statement of Dr Mitchell, Exhibit 1, 584[15].

   [122] Though noting the danger associated with infusing too much fluid is that it causes hypervolemia (fluid overload) and places greater burdens on the heart to push blood around the body.

3. According to Dr Jarvis, such review was requested. Dr Abinesh Dhital and Dr Conan Hall, the ICU Outreach Registrar, came to where Rozalia was in the ED. Dr Jarvis’ recollection was that he met the two doctors outside the room. He outlined his concerns to them:

   My concerns were that Rozalia was still continuing to be at low – continue to have low blood pressure and high heart rate despite our treatment and that the next potential level of treatment that she may require would be medication to support the heart and that was why I was wanting their involvement.[123]

   [123] T124.10-14.

4. The ICU doctors in turn requested that the Consultant Paediatrician review Rozalia before they would become involved.

5. It was Dr Jarvis’ impression that the ICU doctors were going to return after that had happened.[124]

   [124] T124.1-7.

6. Dr Jarvis did not see an ICU doctor review or examine Rozalia.[125] Dr Jarvis said in evidence that he later informed Dr Mitchell that the ICU had not clinically reviewed Rozalia, and that they indicated they would attend to Rozalia after Dr Mitchell had reviewed her first, as that was the impression he had formed during his conversation with them.[126]

   [125] T124.15-20.

   [126] T125.29-32.

7. Dr Hall and Dr Dhital gave evidence that they attended, but did not examine, Rozalia, nor did they check the available records and results.[127] Dr Dhital said that the ICU were not actually requested to attend, but they went to see Rozalia in case she needed ICU care later.[128] They formed the impression that they were not required to do more than attending, pending a review by the Paediatric Consultant (that is, Dr Mitchell).[129]

   [127] T440.5-10.

   [128] T437.30-40.

   [129] T441.7-10.

8. Dr Hall gave evidence that a “proper review” of Rozalia by ICU clinicians would have included taking a history, an examination, and looking through the investigations and observations, as well as looking at the pathology results.[130]

   [130] T425.1-14.

9. Dr Dhital gave evidence that “admitting a paediatric sick patient into the ICU is always out of [their] comfort zone”.[131] Dr Hall said he was not experienced with paediatric patients.[132]

   [131] T437.37.

   [132] T423.1.

10. Dr Mitchell, who was ultimately directing treatment, gave differing accounts as to what she was told about the ICU review or whether she was under the impression that an ICU review had occurred as requested.[133]

    [133] T159.18-19.

11. In the first of the three documents recording Dr Mitchell’s version of events,[134] Dr Mitchell recorded the following:

    Dr Jarvis informed me that the ICU Registrar had reviewed Rozalia, that he had no suggestions to make with regards to further management and felt that ICU care was not required. I was told that an ICU Registrar would await my review.

    [134] Exhibit 6, page 2, para 2.

12. In her second statement, Dr Mitchell added:[135]

    [I said] What do they mean by that? Are they going to take her to ICU? Did they make any suggestions about management? Dr Jarvis said ICU did not feel they had anything further to offer in terms of management and did not feel that she required admission to the ICU.

    [135] Statement of Dr Mitchell, Exhibit 1, 2659[10].

13. There was no clinical note from the ICU to inform Dr Mitchell or anyone else of what, if any, review had taken place. With the benefit of hindsight, Dr Mitchell agreed that in light of the absence of a note indicating what the ICU had thought or planned, she should have followed up with the ICU.[136] Dr Mitchell maintained in her evidence that had she been told by Dr Jarvis that the ICU doctors were awaiting her review before they would become involved, she would have contacted the ICU.[137]

The Experts Review of the ICU Consultation

[136] T160.36-42.

[137] T 191.5-20

1. The experts attached some significance to the ICU’s failure to undertake the requested review.

2. Dr Day thought that it was unusual that the ICU doctors attended but did not review Rozalia.[138]

   [138] T559.31-36.

3. Dr Festa thought that when someone had “gone to the trouble of notifying the ICU” of a patient with low blood pressure, it is incumbent on the ICU to perform a full assessment, whether they have been asked to do so or not.[139] In his view, inotropic therapy should have been specifically discussed and documented, following a full assessment.[140] By necessary implication, Dr Festa regarded the failure by the ICU to assess Rozalia as a “missed opportunity” to have considered additional or alternative causes of the hypotension and shock, including cardiogenic shock[141].

   [139] T558.25-28.

   [140] T558.43-45.

   [141] Expert report of Dr Festa, Exhibit 1, 2640. These comments were directed at what he thought was an undocumented review.

4. Associate Professor Starr said that he would have expected a thorough assessment and a plan.[142]

   [142] T559.19.

5. The experts’ criticisms in this context were accepted by senior clinicians and administrators at the hearing. Dr Simon Robertson, the ICU Consultant who became involved in Rozalia’s care on 5 July 2022, also gave evidence that he would have expected the ICU Registrars to:

   (a)check the notes at some point;

   (b)see what, if any, pathology results were available; and

   (c)examine the child “in most instances”.

6. Dr Samuel Scanlan, Senior Staff Specialist in Emergency Medicine at TCH and Clinical Director for the ED at CHS, gave evidence at the hearing. He conceded that generally there had been “some discomfort” on the part of ICU staff becoming involved in paediatric cases.[143]

   [143] Dr Scanlan, T 618.1-7.

Review of the ECG

1. Dr Jarvis reviewed the ECG trace[144] at about 0655 hours.[145] At the time, he did not interpret it to disclose significant abnormalities, other than an elevated heart rate.[146] In oral evidence at the hearing, Dr Jarvis was of the view that the ECG was consistent with a diagnosis of myocarditis-pericarditis.[147]

   [144] T121.29.

   [145] TCH Clinical Notes, Exhibit 1, 283.

   [146] T121.36-38.

   [147] T121.434-44.

2. Whilst the clinical notes did not refer to it,[148] Dr Mitchell gave evidence that she reviewed the ECG,[149] presumably at the time of her review at 0730 hours. Dr Mitchell said that she thought the ECG “felt to be normal”.[150] Dr Mitchell gave evidence at the hearing that she had been mistaken and was now of the view that the ECG was not normal and was consistent with pericarditis.[151] Given it was consistent with pericarditis, she said it “should alert you to the fact that there may be underlying myocarditis”.[152]

   [148] TCH Clinical Notes, Exhibit 1, 230-231.

   [149] T162.38.

   [150] Statement of Dr Mitchell, Exhibit 1, 584[17]; see also T163.1-6.

   [151] T163.15-27.

   [152] T163.33-34.

3. Dr Robertson, the ICU Consultant who eventually took over Rozalia’s care, agreed that the ECG showed abnormalities that were suggestive of cardiac issues.[153]

Expert Review of the ECG

[153] T377.16-17.

1. Dr Day and Associate Professor Starr agreed that the ECG trace was consistent with pericarditis.[154]

   [154] Expert report of Dr Day, Exhibit 1, 2521[21]. Supplementary report of A/Prof Starr, Exhibit 1, 2610[6.4]. See also T564.43-T565.7, T565.34-36 and 40-45.

2. Associate Professor Starr explained that “myocarditis and pericarditis occur in a continuum. Inflammation of one [the pericardium] frequently results in or includes inflammation in the other [the myocardium].”[155]

   [155] Expert report of A/Prof Starr, Exhibit 1, 2610[6.4].

3. Dr Festa described the abnormality on the ECG as “clear when you are looking for it” and stated that the person looking at it was not experienced enough or not looking for it because it was not listed in the differential diagnoses.[156]

   [156] T590.14-23.

4. He went on to say:

   So I can imagine people coming to the bedspace and not looking for the problem that is shown on the ECG. But the ECG's been done or ordered by someone for the purpose of looking for this thing but that's – there's no continuity in the thinking. So there's a disconnect between the investigation and the primary caregivers in this case, in my opinion.[157]

Dr Mitchell’s first review at 0725 hours

[157] Ibid.

1. Dr Mitchell examined Rozalia at approximately 0725 hours.[158] Her findings included an enlarged liver.

   [158] TCH Clinical Notes, Exhibit 1, 230.

2. Dr Mitchell did not appear to have been made aware that a troponin test had been ordered,[159] nor was she aware that a positive result for influenza A was available at approximately 0734 hours, at about the time her review.[160] Dr Jarvis and Dr Mitchell did discuss outstanding test results just after her review of Rozalia.[161]

   [159] T126.37-41

   [160] T164.35.

   [161] Exhibit 1, 2663[25].

1. At around 2115 hours, Dr Robertson was called back to the hospital and was requested to intubate Rozalia to enable transfer. Her clinical peripheral blood perfusion had worsened, and recent arterial blood gases showed worsening lactate.[337]

   [337] Statement of Dr Robertson, Exhibit 1, 694[28].

2. On arrival at Rozalia’s bed, Dr Robertson noticed that Rozalia had obviously deteriorated and had a narrow pulse pressure, mottling of the arms and was very drowsy.[338]

   [338] Ibid [30].

3. Rozalia went into cardiac arrest at about 2144 hours. Dr Robertson commenced ventilation, followed by full resuscitation measures.[339]

   [339] Ibid [32]-[49].

4. Intensive resuscitation attempts were made, which included intubation at 2149 hours,[340] with 21 doses of adrenaline.[341]

   [340] Ibid 695[34].

   [341] Expert report of Dr Festa, Exhibit 1, 2642.

5. At 2252 hours, resuscitation ceased, and Rozalia was pronounced deceased.[342]

PART 8 – MANNER AND CAUSE OF DEATH FINDINGS

[342] Statement of Dr Robertson, Exhibit 1, 698[49], noting the time was incorrectly noted as 2242 hours. See also NETS Notes, Exhibit 1, 814.

1. As required by s 52 of the Act, I make the following finding as to the cause of Rozalia’s death:

   That Rozalia Spadafora died at 2252 hours on 5 July 2022 at the Canberra Hospital, Garran, in the Australian Capital Territory, as a result of myocarditis.

2. As to the manner of Rozalia’s death, I make the following findings:

   (a)It is not possible to know precisely when myocarditis had developed as a complication of the influenza A Rozalia had contracted before her attendance at TCH, and why Rozalia suffered that complication.

   (b)GPs who were consulted by Katrina took the appropriate steps to diagnose Rozalia’s condition, noting that myocarditis is rare and difficult to diagnose outside of a hospital setting.

   (c)Dr Yesmin acted appropriately by advising Katrina that Rozalia should re-present to a GP if her condition became worse. Dr Yesmin’s decision to refer Rozalia to the ED of TCH was correct. The decision reflected her belief that the testing Rozalia required would be undertaken more quickly if she went to the ED.

   (d)Dr Yesmin’s failure to send an accompanying letter would not have affected the triage category that was determined at the ED.

   (e)Rozalia arrived at TCH at about 1900 hours. She was triaged in the ED at about 1940 hours. The triage category assigned to Rozalia – Category 3 – was appropriate.

   (f)That category should have seen Rozalia reviewed by a doctor within 30 minutes.

   (g)Rozalia was not reviewed by a doctor until 0016 hours, over 5 hours after she presented at TCH, and around 4.5 hours after she was triaged. Rozalia’s best chance of survival was to be transferred to a children’s hospital in Sydney as quickly as possible for specialised interventions including, if necessary, ECMO. That delay in the ED may have been significant in the clinical course that followed.

   (h)Observations were continued in the ED after the triage process. Rozalia’s condition deteriorated. Her blood pressure should have been taken at 2155 hours. If, as was likely, her blood pressure was low, it would have prompted a medical review at around 2155 hours. If that had occurred, it would have likely led to a change in her triage category. There is no evidence that re-triage was considered, despite the changes in her observations. Rozalia was not seen by a doctor within 30 minutes, in accordance with triage guidelines.

   (i)The evidence does not explain why the failure to adhere to the 30-minute review time in Rozalia’s case did not result in any follow up by a CIN. It is most likely the designated CIN performed general duties in the undoubtedly busy ED throughout the time Rozalia was waiting to be seen by a doctor. The safety net function of the CIN effectively lapsed during that period. There was not a CIN rostered overnight.[343] The CIN process failed to achieve its intended outcomes.

   [343] This information was provided by the Territory after the hearing.

   (j)Rozalia was first reviewed at 0016 hours by Dr Wong, who was assigned to the paediatric area in the ED. Dr Wong had no specific training in paediatrics, reflecting a lack of paediatric capacity in the ED. His assessment that Rozalia’s condition was attributable to a viral illness was reasonable. Dr Wong did not measure Rozalia’s blood pressure and did not have regard to the observations made after triage, which indicated a deterioration of her condition.

   (k)It is likely that Dr Wong did not tell Dr Jarvis, the Paediatric Registrar, of his suspicion of a viral illness.

   (l)The notes made of the 0016 hours review were described by the experts as lacking detail. There was no list of differential diagnoses and no treatment or diagnostic plan, other than to refer to a specialist team and to take bloods.

   (m)The review conducted by Dr Jarvis and Dr Tee at 0420 hours was thorough. Low blood pressure was identified, as was tachycardia. An enlarged liver was identified. Dr Jarvis correctly associated those symptoms with a possible cardiac cause, such as myocarditis or pericarditis. That resulted in the ECG being conducted at 0652 hours.

   (n)The ECG was abnormal and suggestive of pericarditis. The abnormality was clear if read in light of the purposes for which the test was ordered.

   (o)The ECG was reviewed by Dr Jarvis and Dr Mitchell at around 0730 hours. The ECG was misread by both Dr Jarvis and Dr Mitchell as indicating no significant abnormalities.

   (p)A positive influenza A result was available at 0724 hours.

   (q)By about 0740 hours, there was enough information to suspect myocarditis, even in the absence of the troponin result. That being so, the amount of fluids that was being administered to Rozalia was in excess of what was required and may have been further damaging Rozalia’s heart. Given the seriousness of her condition, preparations should have commenced at that time for transfer to Sydney through NETS. Her condition at that time would have made the process of intubation and ventilation required for transfer more viable than it was to be the case over 12 hours later.

   (r)The decision taken by Dr Watson to include a troponin test to exclude myocarditis was sound. Given the request was received at 0644 hours, there should have been a result by around 0815 hours. No one appeared to have been allocated the responsibility of following up on that result. The result should have been followed up by Dr Mitchell or a member of the ED team. It was not an adequate response for the clinicians involved in Rozalia’s care, including Dr Mitchell and the ED clinicians, to presume that an adverse result would have been communicated to them.[344]

   [344] See for example Dr Mitchell, T166.13-17.

   (s)Dr Mitchell made a request for an ICU review at some time shortly after her conversation with Dr Jarvis at around 0530 hours. That request was made for a sound clinical purpose. That review should have taken place and should have included the taking of Rozalia’s history, a physical examination, a review of the observations, and a consideration of the investigations ordered. It was an opportunity lost to have fresh eyes brought to the process of clinical assessment. The ICU’s reluctance to undertake a review and the apparent deference to paediatric opinion before they would become involved was likely attributable to Dr Hall and Dr Dhital not being experienced in paediatrics. This reflects a lack of paediatric capacity in the ICU at that time.

   (t)There is a divergence in the evidence as between Dr Jarvis and Dr Mitchell as to whether Dr Mitchell was told whether an ICU review had occurred. The fact that a review had not been undertaken was not properly documented. In the absence of notes of an ICU review, Dr Mitchell should have checked with the ICU as to what had happened or what was to happen, as far as a review was concerned.

   (u)The handover processes in the ED, the ICU, and Paediatrics conducted between 0800 and 0830 hours were inadequate:

   (i)Rozalia’s care was discussed at the Paediatrics, the ED, and the ICU handovers. Doctors should have acted on an already available diagnosis of myocarditis.

   (ii)The information available and discussed at the Paediatrics and the ED handovers was both siloed and, in some respects, different.

   (iii)Rozalia’s enlarged liver and the potential for a cardiac cause for her condition were discussed at the Paediatrics handover, but not subsequently acted upon in a co-ordinated way.

   (iv)The outstanding troponin test and a suspected infection were discussed at the ED handover.

   (v)Both Paediatrics and the ED appeared to have incorrectly assumed a greater level of involvement by the ICU than was actually the case, or, at least, there was an inconsistent understanding between Paediatrics and the ED regarding the level of ICU involvement.

   (vi)The suggested improvement in Rozalia’s presentation was not consistent with her clinical observations.

   (vii)As a result of the inconsistencies within the day sheet, no doctor in the ED considered themselves to be responsible for Resus bed 2 and Rozalia between 0800 and 1007 hours.

   (v)Confusion about the extent of ICU involvement continued after the handover.

   (w)Fluids for dehydration continued to be administered in excess of the amount needed, placing greater strain on Rozalia’s heart. Rozalia was transferred from Resus bed 2 to bed 41 in the Paediatric ED without medical review and despite her PEWS score having risen to and remained at 6.

   (x)There was a delay in the troponin result being actioned. The troponin result:

   (i)should have been available by about 0815 hours at the latest;

   (ii)was available at 0956 hours and was delivered to Rozalia’s bed on a post-it note, attached to Rozalia’s records on the scribe table, at some time between 0956 and 1005 hours. That form of communicating an abnormal result was unacceptable;

   (iii)was known by nursing staff shortly prior to 1005 hours;

   (iv)was known, to the extent that it was positive, as opposed to the actual number, by at least Dr Watters, and probably Dr Stewart at about 1025 hours;

   (v)was definitely known, to the extent that it was positive, as opposed to the actual number, by Dr Stewart at about 1130 hours;

   (vi)was assumed by Dr Stewart to have been known by Dr Mitchell and to have been the subject of the formal critical result process; and

   (vii)was brought to Dr Mitchell’s attention just after midday and actioned, causing a change in treatment, including the reduction of fluids and the engagement of NETS.

   (y)Had the troponin result been brought to Dr Mitchell’s attention earlier, the treatment that commenced at about 1220 hours would have likely commenced as soon as the result was known.

   (z)The discovery of the troponin result caused Dr Mitchell to diagnose myocarditis and to change the treatment plan, which included reducing fluids and engagement with NETS. Clinical decision making thereafter was informed by discussions with clinicians in Sydney:

   (i)Rozalia was moved to the ICU at 1220 hours, pending the arrival of NETS;

   (ii)The opportunity to attempt to transfer Rozalia to Sydney was prior to 1900 hours, and probably significantly before 1900 hours;

   (iii)There was some delay in the attendance of NETS, due to operational and environmental issues concerning the teams gaining access to a helicopter. That unquantified delay was not consequential to the ultimate outcome. Rozalia was likely very unwell by the time of Dr Mitchell’s assessment at around midday on 5 July 2022;

   (aa)NETS first saw Rozalia at about 1915 hours. By that time, Rozalia’s myocardium was failing and fatiguing.

   (bb)Rozalia’s observations between 1900 and 2141 hours were consistent with a terminal decline in heart functions.

   (cc)Rozalia was too unstable to be transferred.

   (dd)Intensive resuscitation efforts were adequately performed, but they were unsuccessful.

   (ee)Rozalia died at 2252 hours on 5 July 2022.

PART 9 – SECTION 3BA OF THE ACT – CONSEQUENCES OF THE DELAY

1. During the inquest, Rozalia’s mother made clear her belief that Rozalia’s life could have been saved if she had been airlifted to Sydney in a timely manner. Whilst consideration of that issue will inevitably involve an element of speculation, I believe that s 3BA of the Act does oblige me to attempt to answer that question.[345]

   [345] Section 3BA of the Act provides that as far as is practicable, the objects of the Act must, for an inquest into a person’s death, be carried out in a way that recognises that the family and friends of a deceased person have an interest in having all reasonable questions about the circumstances of the person’s death answered.

2. In this context, there are a number of factors that will have to be considered and assessed:

   (a)Fulminant myocarditis is a serious condition, and it can cause death. Associate Professor Starr gave evidence that up to 50% of children with that condition die regardless of the clinical intervention.[346]

   [346] A/Prof Starr, T594.22.

   (b)After diagnosis was made, proper treatment had to be administered, including reducing the fluids being administered and considering inotropic support.[347]

   [347] Dr Day, T590.35.

   (c)Rozalia’s best chance of survival was then to be transferred to a hospital in Sydney to allow specialised interventions, including ECMO and, if indicated, heart transplant, to take place.

   (d)To be airlifted to Sydney, Rozalia had to be stable enough to be intubated and ventilated. Doing so “would have been a challenging moment in her care and she may have had a cardiac arrest on intubation”.[348]

   [348] Dr Festa, T592.3.

   (e)The earlier that attempt to intubate and ventilate was made, the better. As Dr Festa said, “I think the sooner you do that, in the context of… somebody whose heart is tired, fatigued, and less able to tolerate the stresses being put on it, the better, because you have to give intubating drugs, anaesthetic drugs, and every single one of those will, to some extent, weaken the power of the heart muscle to squeeze”.[349]

   [349] Dr Festa, T592.5-10.

   (f)Dr Festa indicated that “earlier recognition of cardiogenic shock” would have created “a window of opportunity” for Rozalia to be transferred to Sydney. He said “that’s based on earlier diagnosis and also optimised treatment choices made post-diagnosis.” With earlier diagnosis and appropriate treatment, there “would have been an opportunity for her to be retrieved by NETS to a Sydney Hospital”.[350] However, even if that occurred, “I’m not prepared to say there would have been a change in outcome as a result of that”.[351]

   [350] Dr Festa, T591.39-45.

   [351] Dr Day, T591.32.

   (g)Once in Sydney, the success of specialised interventions was not guaranteed. Dr Festa indicated that once ECMO is initiated, survival rates are somewhere between 48% and 77%. On a statistical basis, Dr Festa chose 50% or slightly over as the likelihood of survival. In some cases, survival occurs because of a heart transplant.[352]

   [352] Dr Festa, T593-594.

1. Based on the experts’ opinions, I find that the delay in Rozalia’s diagnosis and the failure to provide Rozalia with appropriate treatment in a timely manner meant that any opportunity Rozalia may have had for survival was lost.

PART 10 – SECTION 52(4) OF THE ACT – PUBLIC SAFETY ISSUES

1. For the purpose of s 52(4) of the Act, I find that a number of matters of public safety arise in connection with the inquest.

AN OVERVIEW

1. Mr David Peffer, Chief Executive Officer of CHS, gave evidence at the hearing. In both his statement and his evidence, Mr Peffer made concessions as to the inadequacy of Rozalia’s care, saying that “the care provided by CHS to Rozalia Spadafora and her family did not meet the standards CHS should be able to provide to our patients, their families and loved ones”.[353] He identified the following matters as making up that shortfall in care, and which I find to be matters of public safety:

   [353] Statement of Mr Peffer, Exhibit 11.7, [13].

   (a)Rozalia, her mother, and her grandmother had to wait too long to be seen by a doctor. Once seen, systems and processes of CHS let Rozalia and her family down and were not sufficiently robust to support clinicians and staff to provide the best care to Rozalia Spadafora and her family.

   (b)There are a number of ways in which systemic issues did not support the provision of best care to Rozalia:

   (i)Overall timeliness in review of Rozalia in the ED;

   (ii)Lack of clarity about responsibility for overall management of Rozalia upon her presentation;

   (iii)Internally contradictory information in day sheets in the ED, which did not conform to the system in the ED for allocation of consultants to resuscitation beds;

   (iv)Weaknesses in the system for processing add-on pathology requests, affecting the timeliness of processing of the troponin test request and leading to a delay in the notification of the Troponin test result from Pathology; and

   (v)Vulnerability in the system for notification of urgent pathology results, which meant that the troponin result was not immediately notified to a clinician.

2. CHS, through various witnesses, provided information in the inquest and the hearing as to the extent to which these issues have been addressed since Rozalia’s death.

WAIT TIMES IN THE ED – THE CIN POSITION

1. The delay Rozalia experienced in being reviewed by a doctor after her presentation at the ED was an experience shared by other paediatric patients at the time. For the period of 1 July 2022 to 30 September 2022, 26% of the paediatric triage Category 3 patients were seen on time. In respect of all paediatric patients, 41% were seen on time. Changes implemented after Rozalia’s death, though not defined, saw that position improve. During the comparable period in 2023, 45% of paediatric triage Category 3 patients were seen on time and an overall of 56% of the paediatric patients were seen on time (meaning 44% were not).[354]

   [354] Statement of Dr Scanlan, Exhibit 11.8, [24].

2. It is accepted that long wait times in EDs are a problem experienced in hospitals across Australia. Other than to observe that, as may be the case with Rozalia, delays can result in deferred treatment and poorer clinical outcomes, I make no comment about the general issue of delays experienced at the ED at TCH. It would obviously be desirable that paediatric patients are seen by a doctor in the timeframes contemplated by their triage categories.

3. However, the detrimental effect of such delays can be ameliorated to some degree. The CIN position still exists at TCH. An important aspect of the design of the position is to ensure that patients who are not being assessed in accordance with their triage category are kept under observation and re-assessed to determine whether their condition is deteriorating and to negotiate a change in ED priorities if that is appropriate.

4. As it has been noted, the Court has received no information as to why the CIN process did not operate effectively on the evening of Rozalia’s presentation. Clearly, staffing and resourcing were an issue. It appeared that the person occupying the CIN position was used to meet the staffing demands within the ED, and no CIN was rostered overnight. This is likely to happen if the CIN position is regarded as a potential backup when staffing shortfalls in the ED arise.

Recommendation

1. The CIN position is most needed when the demands of the ED are the greatest.

2. I recommend that CHS adopts a staffing model that ensures the CIN position is filled on a 24-hour basis and quarantines the CIN position from the staffing demands of the ED.

ADD-ON REQUESTS AND NOTIFICATION OF PATHOLOGY RESULTS

1. The evidence suggested that the reporting of the troponin result was slow and the processes of bringing results to the attention of the relevant clinicians were far from robust. With the introduction of the Digital Health Record (“DHR”), add-on requests are dealt with in a more efficient way. Add-on requests now have a separate process and the “add-on basket”, as it is styled, is constantly monitored.

2. Importantly, there is now an agreed list of critical results, which includes troponin, which requires notification directly to a clinician, rather than an ED Clerk.[355] Dr Scanlan gave evidence that “tier one” results on the list, which include troponin, are reported directly to the senior emergency doctor in the department, who carries the admitting officer phone. He also confirmed that the laboratory will no longer call a clerical or administrative team member to notify them of critical results, but will instead call the admitting officer.[356]

   [355] Statement of Mr Newton, Exhibit 11.5, 7[27].

   [356] T644.35-40.

3. In light of these developments, I make no recommendation in respect of this issue.

PAEDIATRIC INTENSIVE CARE UNIT & PAEDIATRIC SPECIALISATION IN THE ED

1. The lack of an appropriate paediatric capacity within the ED and ICU was evident in Rozalia’s care. As Mr Peffer noted in his statement and in evidence, there has been a debate over many years about an appropriate model of care for seriously unwell children. Historically, TCH has operated without a paediatric High Dependency Unit (“HDU”) or a paediatric Intensive Care Unit (“pICU”).

2. The recent and complicated history of the consideration of this issue was detailed by Mr Peffer in evidence. In short, as to the initiatives that have been implemented or soon to be progressed:

   (a)there are now four paediatric beds in a new ICU for the care of sick children who meet an agreed referral pathway;

   (b)there is a proposal to create a paediatric Close Observation Unit (“COU”) in the paediatric ward, which would provide an intermediate level of care between the general paediatric ward and the ICU. Staff members would rotate between the COU and the ICU to improve the level of paediatric critical care; and

   (c)a dedicated paediatric stream in the ED with its own triage area has been created. The aim is to ensure that the ED’s paediatric functions would be given priority to ensure that the paediatric area is not closed, even at times of staff resourcing pressure.

1. These developments have the potential to generally improve the standards of paediatric care at TCH. However, in respect of Rozalia’s care, issues arose in a slightly different context, which may not be directly and positively addressed by these recent developments:

   (a)the paediatric function within the ED was open at the time Rozalia was being treated. However, it was obviously very busy and the rostered clinical staff did not have a high level of exposure to paediatric medicine; and

   (b)the ICU Outreach staff did not have a high level of exposure to paediatric medicine and, for that reason, were hesitant in engaging in assessments associated with Rozalia’s care.

1. To avoid a repetition of what happened in Rozalia’s case (that is, the delays in ED assessments and the lack of paediatric expertise in the ED and the ICU), CHS should ensure that staffing levels and paediatric skill profiles in both the Paediatric ED and the ICU, including its Outreach function, are maintained at levels that will ensure that paediatric patients who present through the ED, particularly out of normal business hours, are provided with an adequate standard of care.

2. The changes that have been made or proposed in respect of the ICU paediatric unit and the Paediatric ED function should assist in building that capacity. Recent recruitment activities have also added to enhance TCH’s paediatric capability.

Recommendation

1. I recommend that those involved in the implementation of the new ICU and the Paediatric ED, as well as the planning of the paediatric COU, consider the evidence in this inquest and my findings.

2. Orders will be made to facilitate access to the brief of evidence and transcripts for senior CHS and TCH staff members.

HANDOVER ISSUES

1. In November 2022, TCH introduced the Digital Health Record (“DHR”) system.

2. Dr Scanlan explained that the DHR is a single unifying system that allows for the requesting of investigations, results, documentation, notes, and parts of the handover process to be in one system. Clinical and administrative records are now directly entered into the DHR by doctors, nurses, and clerks.[357]

   [357] Statement of Dr Scanlan, Exhibit 1, 784[15].

3. There is also a module in the ED, called “ASAP”, that tracks patients progress through the ED.[358]

   [358] T610.15-20.

4. DHR has functionalities that may address some of the system shortfalls as seen in the context of Rozalia’s care:

   (a)Against patient names, it identifies radiology or pathology requests made, and whether those results are available.[359]

   [359] T620.9-12.

   (b)It creates automatic warnings and escalation within DHR when paediatric observations are deteriorating.[360]

   [360] Statement of Mr Peffer, Exhibit 11.7, 10[41].

   (c)In respect of handover issues, the Day Sheet process remains (now corrected to ensure consistency). However, DHR will tell staff if they have not handed over a patient to another doctor on the system. An incoming doctor cannot be allocated patients until they have signed into the DHR. They must then assign each patient to themselves. It is not clear whether the outgoing doctor has to confirm that a patient has been accepted by the incoming doctor.

   (d)The DHR incorporates a track board, which is an overarching view of the department, listing all of the patients’ name, age, triage category, presenting problem, and the clinician who is looking after them.[361]

   [361] T612.40-45.

1. Subject to the reservation that follows, I find that the introduction of the DHR has the potential to improve information flow between clinicians during the handover process.

2. The evidence showed that four disparate handovers were conducted in relation to Rozalia, each one conveying different “pieces of the puzzle’’ that made up Rozalia’s diagnosis. No notes were made in Rozalia’s records of the content of any of those handovers, and there is no suggestion that handover notes are now uploaded to the DHR. Witnesses present at the same handover recalled different information having been provided. Clinicians who would have benefited from a handover, such as those in  the Paediatric ED, did not participate in one. There is no evidence that the information from handovers in Rozalia’s case or now is shared formally between the specialties, departments, or locations. The impression is one of siloed information.

3. The experts gave evidence of systems that require patients to be handed over before clinicians can log out of the electronic system and of interaction and the exchange of information between different disciplines or specialties/departments caring for the same patient.

Recommendation

305.    I recommend that CHS reviews the functionalities of the DHR in respect of handover processes, in light of the evidence given in this inquest.

INFLUENZA VACCINATIONS

1. The evidence given by the experts was that vaccinations for children aged between 6 months to 5 years old are free. However, the majority of children are not vaccinated and are, therefore, exposed to an illness that can cause significant complications, sometimes requiring hospitalisation, including myocarditis. The experts noted that whilst the influenza A vaccine might not be the best vaccine, in the sense of providing consistent protection,[362] its use amongst young children of this age group was a good idea, and GPs should be encouraged to talk to families about getting their children vaccinated. Dr Day put it this way:

   [362] A/Prof Starr, T604.25.

   Rates are slowly increasing again [after COVID], but certainly anything that can be done to increase that uptake is valuable and the reasons for that are that they're a big group of spreaders, not just amongst themselves but also to younger siblings under six months and to older people, such as grandparents, who may be at high risk of getting complications from influenza, and certainly things like influenza cause a great burden of disease on GPs and emergency departments in the winter months, and a higher rate of vaccination amongst the six-month to five-year-old group would be helpful to the community in many ways.[363]

   [363] Dr Day, T604.11-19.

2. The experts did make the point, and it should be emphasised, that even if Rozalia had been vaccinated, she may still have contracted Influenza A.[364]

   [364] A/Prof Starr, T604.31.

Recommendation

308.    I recommend that CHS and ACT Health actively promote influenza vaccinations amongst children aged between 6 months and 5 years old.

PART 11 – SECTION 55 NOTICES

1. My proposed findings contained comments adverse to a person (the Territory) and Dr Tze Hao Wong, Dr Anne Mitchell, Dr Callum Jarvis, Dr Abinesh Dhital and Dr Conan Hall. Consistent with my obligations under s 55 of the Act, I provided the Territory and those doctors with a copy of the proposed comment, with advice consistent with that section as to how the they may respond. The section 55 process affords people who are commented upon adversely in a “finding or report” to make a submission in respect of the proposed comment or give the Coroner a statement in relation to it. If a statement is given to the Coroner, it or a fair summary of it must be included in the report if the person so requests.

2. On 22 October 2024, pursuant to s 55 of the Act, a notice was served on the Territory and the doctors referred to above [309], together with my provisional findings. Responses were received from Dr Tze Hao Wong and Dr Callum Jarvis, both in the form of a submission. Two changes were made to the wording used in my provisional findings in light of the submissions made by Dr Wong and Dr Jarvis.

3. By letter dated 6 November 2024, the Territory pointed out two typographical errors or omissions in the provisional findings and forwarded a statement from Ms Janet Zagari, the Deputy Chief Executive Officer of Canberra Health Services. A request was made to include that statement in my findings. I formed the view that the content of that statement went beyond the scope of a response to the adverse comments that had been foreshadowed. The Territory were invited to re-consider their response. By letter dated 25 November 2024, a new statement signed by Ms Zagari on 22 November 2024 was provided. As requested by the Territory, I include a copy of that statement with these findings. My findings will, for the purposes of s 57 of the Act, constitute my report to the Attorney-General of the inquest I have conducted.

I certify that the preceding three hundred and eleven [311] numbered paragraphs are a true copy of the reasons for findings of his Honour Coroner Archer.

Associate: Markus Ching

Date: 6 December 2024