Queensland Health Ombudsman report into death of Bamaga child Charlie Toza found deficiencies

A health service says it addressed systemic failures leading to the death of a six-year-old boy at Bamaga Hospital, just nine months before the sudden death of a two-year-old girl in the remote town.

A health service says it addressed systemic failures leading to the death of a six-year-old boy at Bamaga Hospital, just nine months before the sudden death of a two-year-old girl in the remote town.

Little is known about the tragic passing of the two-year-old in the Cape York township of Bamaga, with a coronial investigation under way and a community in mourning.

Former Torres and Cape Hospital and Health Service CEO Beverley Hamerton said Bamaga Hospital staff worked hard to save the child’s life when the family presented to hospital, and “all appropriate care was provided to the child”.

But a 2020 report into the tragic death of a six-year-old revealed systemic failures at Bamaga Hospital.

Health Ombudsman Andrew Brown made 20 recommendations in a 108-page report, released in September 2020, three years after Charlie Gowa died on January 14, 2017.

The recommendations were designed to address “significant issues and areas for improvement” and revolved around clinical record keeping, hospital staff recognising deterioration in patients, communication and culture, the hospital’s model of care, resourcing and inductions, clinical incident reviews, and open disclosure.

TCHHS interim chief executive Dean Davidson said a coronial investigation into Charlie’s death found “while aspects of Charles’s care was not optimal, it was reasonable for the medical officers involved in his care not to have actively considered a working diagnosis of melioidosis while he was at Bamaga Hospital’’.

He said 20 recommendations from the 2020 report were implemented by October 2022.

The report exposed a litany of failures in the five days before Charlie’s family made the heartbreaking decision to switch off life support in a Brisbane intensive care unit.

Charlie’s mother took him to the hospital on January 9, saying he had been unwell for several days, and was told “there’s a gastro bug going around”.

Charlie was given an ice block and Panadol.

The following day Charlie’s mother took him back, waiting two hours to see a doctor.

He was again sent home with Panadol, although she felt “a growing sense of worry” and his father “was angry the hospital would not do more”, the report said.

Six-year-old Charlie Toza was flown to Cairns Hospital after presenting on five consecutive days to Bamaga Hospital and being sent home again. Picture: Brendan Radke

On January 11, a Saturday, Charlie’s mother took him back to the hospital but was told there were no doctors working on weekends.

“She was told to come back with Charlie on Monday,” the report stated.

As Charlie continued to deteriorate severely, his mother took him back on January 12 and was again told there was no doctor available.

“Charlie’s parents did not know what else they could do for their son but to keep taking him to hospital in the hope that someone would do something,” the report stated.

Charlie’s mother took him back on Monday, January 13.

“After a long wait, a doctor came to see Charlie where he was given Panadol again and sent home,” the report said.

On Tuesday, Charlie’s dad stayed home from work again so his mother could take him to the hospital.

“Charlie could barely walk and one side of his face seemed swollen and really puffy like he had been hit in the head and it had filled with fluid,” the report said.

“Charlie could not walk straight and said his legs hurt.

“At last, Charlie was taken to a hospital bed where a doctor checked him over.”

Charlie Toza, 6, was placed in a category for transport by the Royal Flying Doctor Service “between six and 24 hours”.

A decision was made to send Charlie with Royal Flying Doctors to Cairns Hospital, but there was a delay.

On Wednesday, Charlie and his father were flown to Cairns Hospital and straight to emergency “but they could not find his chart from Bamaga Hospital”.

He was moved to the intensive care unit and intubated, and his parents were told it was suspected he had melioidosis – a bacterial infection picked up from dirt in the tropics.

Charlie’s father was told Charlie was fighting for his life and his heart was not strong enough to beat by itself.

A specialist team had been called to Cairns.

He was flown straight to Brisbane with the specialist team, although his father was told he couldn’t come on the flight.

Charlie’s mother, brother and sister flew to Cairns but Charlie was already on his way with to Brisbane with the specialist team.

The family got the next available flight to Brisbane and went straight to Queensland Children’s Hospital to see Charlie, who was in intensive care.

They were overwhelmed by how fast he was slipping away.

Doctors confirmed Charlie had melioidosis and the exhausted family went to their accommodation, but were called back to the hospital early on Saturday morning.

“Charlie’s parents were told their son’s brain was shutting down and it was very likely he would not survive.”

His life support was switched off at 6.48pm that day.

Queensland Children's Hospital in Brisbane, where Charlie Toza died surrounded by family on January 14, 2017.

“The changes needed at Bamaga Hospital to address the issues identified in this report are significant and improvement in these key areas will be challenging,” the report stated.

“This will require sustained effort and support from the highest levels of TCHHS (Torres and Cape Hospital and Health Service) through to individual practitioners working within the facility at any given time.”

It was “a tragic confluence of events, leaving a family mistrusting of a health service that they had to continue to routinely access”.

The report stated “general deficiencies in documentation” hindered the Health Ombudsman’s assessment of the care and treatment provided to Charlie at Bamaga Hospital, including reaching any firm conclusions about decisions not to admit Charlie earlier than January 10.

Charlie was buried at Bamaga.

Originally published as Queensland Health Ombudsman report into death of Bamaga child Charlie Toza found deficiencies