The parents of a 19-month-old boy who died after being wrongfully discharged from hospital wept in court after a coroner ruled his death was preventable.
The Souvatzis family was on holiday in north-east Victoria on 29 December 2021, when Noah developed a high temperature and began vomiting.
His parents, Ben and Steph, took him to an urgent care center in the city, where a nurse at Alpine Health noticed symptoms of lethargy and an increased heart rate.
Noah was taken to Wangaratta Hospital on the advice of his nurse, where Dr Paul Bumford diagnosed him with gastroenteritis and discharged him three hours later despite continuing to vomit.
Noah’s condition worsened so his parents took him to another medical facility in Benalla a couple of hours later, and then Noah was transferred by ambulance back to Wangaratta Hospital.
The boy suffered seizures during the journey and CT scans showed signs of meningitis, so Noah was airlifted to Melbourne’s Royal Children’s Hospital in the early hours of 30 December.
At 3.11pm that day, Noah was declared brain dead and died the following morning.
Coroner Katherine Lorenz ruled on Tuesday that Noah’s tragic death could have been prevented and that he should not have been discharged from Wangaratta Hospital in the first place.
Noah Souvatsis (pictured) was on vacation with his parents when he developed a high fever and vomited.
Noah’s parents Ben and Steph Souvatzis (pictured leaving the coroner’s court on Tuesday) cried as the results were announced. The coroner praised the Souvatzis family for their bravery in launching an inquest.
“This was a clear failure by Wangaratta Hospital in its duty of care to Noah,” Lorenz said.
Ben and Steph Souvatzis sobbed in the Coroner’s Court as the results were announced.
Ms. Lorenz noted that Dr. Bumford was on his first shift at the hospital and in the middle of an induction session when he went to assess Noah.
He was supposed to be second in command of the emergency department, but he did not have enough experience for that position, the coroner determined.
Senior physician Doug Devereux should have evaluated Noah or at least reviewed his medical history before allowing him to be discharged, Lorenz said.
But Dr. Devereux only gave Noah “a brief glance,” even though photos from that day show Noah was clearly very ill and not alert, the coroner said.
Dr Bumford admitted at the inquest that he had misdiagnosed Noah and the coroner concluded that the boy might have survived if he had been given antibiotics on his first visit to hospital.
Ms Lorenz also found that Noah’s outcome might have been different if doctors had listened to Ben and Steph Souvatzis when they raised concerns about their son’s condition.
“Parents know their children best,” he said.
Coroner Katherine Lorenz determined that the 19-month-old boy’s death could have been prevented (pictured: the Souvatzis family)
The coroner said “parents know their children best” and Noah’s tragic outcome could have been different if doctors had listened to his parents’ concerns (pictured, Noah Souvatzis)
The coroner recommended that the Australian Commission on Safety and Quality in Health Care and Safer Care for Children consider advising doctors to ask about and take note of parents’ concerns when routinely monitoring a child patient’s vital signs.
Ms Lorenz praised the Souvatzis family for their courage in pursuing an investigation into a heartbreaking, life-changing tragedy.
The couple did not speak to reporters but made a statement through their lawyer in court, thanking the coroner for listening to them after years of not being heard.
A spokeswoman for Northeast Health Wangaratta said the hospital’s thoughts and condolences remained with the Souvatzis family.
“NHW accepts that Noah did not receive the care he should have received, something which rightly weighs heavily on us as a health service,” the statement to AAP read.
‘We thank the coroner for his findings, which we will now review and are committed to implementing any further improvements.’