Toddler’s tragic death ruled preventable

A 19-month-old boy’s death after he was misdiagnosed at an understaffed hospital was preventable, a coroner has found.

Noah Souvatzis died days after falling ill while holidaying with his family near Myrtleford, in Victoria’s northeast, in December 2021.

About 3am on December 29, his parents, Steph and Ben, woke to find the usually “delightful little boy” vomiting and with a high fever, deciding to take him to an urgent care clinic in town.

Nurses at the facility advised the family to take Noah to Wangaratta Hospital’s emergency department after testing indicated he could have been deteriorating.

They arrived about 3.45pm the same day, and the inquest was told locum doctor Paul Bumford misdiagnosed Noah with gastro and discharged him three hours later after he seemingly improved.

But the inquest was told the boy began to deteriorate again, with Mr and Ms Souvatzis taking Noah to a second urgent care clinic in Benalla that recognised he was seriously unwell.

Noah was eventually flown to Melbourne’s Royal Children’s Hospital the following morning and diagnosed with bacterial meningitis from Streptococcus pneumonia.

He was found to be brain dead later the same day.

Noah’s death was the subject of a coronial inquest, with coroner Katherine Lorenz finding, on the balance of probabilities, his death could have been prevented.

Handing down the inquest findings on Tuesday, she said mortality rates for Noah’s condition among children were between 7 and 15 per cent if treated correctly.

The coroner found Wangaratta Hospital had failed its duty of care by discharging Noah and was critical of the “inadequate” orientation Dr Bumford received on what was his first shift at the hospital.

She said Dr Bumford should never have been rostered as the second doctor in charge, and that senior doctor Douglas Devereux ought to have examined Noah prior to discharge.

Ms Lorenz said she was satisfied many of the issues raise had subsequently been addressed by Northeast Health Wangaratta (NEHW).

“It was conceded by NEHW that Noah should not have been discharged,” she said.

“Discharging Noah in these circumstances was a clear failure of NEHW’s duty of care.”

The coroner also said it was self-evident throughout the inquest that medical staff needed to take more care in listening to parents.

“Parents know their child best,” Ms Lorenz said.

“Allowing parents and carers to independently raise and escalate their concerns is an important safeguard to prevent unrecognised deterioration in children by clinicians.”

She said had Ms Souvatzis been listened to, Noah’s care could have been escalated and his unfortunate death could have been avoided.