Joe’s death must be catalyst for hospital change

“No parent should have to walk out of a hospital with their bags instead of their child.”

This is the devastating situation Sydney couple Elouise and Danny Massa found themselves in when their bright and loving little boy, Joe, died in the emergency department at the Northern Beaches Hospital last year.

The two-year-old had spent the night violently vomiting and retching at their home in North Balgowlah when the couple took him to their local hospital at 7am on September 14. He was suffering from significant hypovolemia, a condition that occurs when the body loses too much fluid.

Joe Massa’s heartbroken parents Elouise and Danny holding a pair of his shoes.Credit: Kate Geraghty

The hospital’s emergency room wasn’t busy and a nurse who was about to finish their night shift triaged the toddler as “category 3” – having a potentially life-threatening condition requiring treatment within 30 minutes. She wrongly thought he had gastro.

But his heart rate was 182 beats per minute and his “pale and flat” appearance indicated his condition was life-threatening and needed an immediate and serious response, independent medical staff said in a review into his death.

Despite the department having paediatric beds available and adequate staffing levels at the time, Joe was not given a bed for two-and-a-half hours as his condition continued to rapidly deteriorate. His mother eventually screamed “my son has gone blind”.

At 10.47am, Joe went into cardiac arrest. CPR was performed by the emergency team for 29 minutes, but Joe had suffered irreversible brain damage and his life support was withdrawn two days later.

Staff at the hospital denied repeated requests for intravenous fluid drips and monitoring equipment.

The review recommended urgent changes to the electronic medical record system and triage processes after finding the hospital failed to respond urgently to a heart rate in the “red zone” and failed to respond to serious concerns from clinicians and the boy’s parents.

The grieving Massa family wants action, including a coronial inquiry into their son’s death and a comprehensive review of Northern Beaches Hospital for what they say is “serious malpractice”.

They are also calling for reviews of the hospital’s escalation procedures and staff training, an IT system upgrade and statewide enforcement of the REACH protocol so all parents know their rights. In Queensland, a protocol known as Ryan’s rule is a three-step process that supports families to raise concerns if a patient’s health condition is getting worse or not improving as well as expected. It was named after toddler Ryan Saunders, who died after a misdiagnosis in 2007. NSW clearly needs a Joe’s rule.

The couple has also urged the state government to re-evaluate its arrangement with Healthscope, the private company contracted to build and run the hospital under a rare and controversial “public-private partnership” with the former Coalition state government. Health Minister Ryan Park said the tragedy “raises serious questions about privatisation and this type of model”.

Healthscope operates 38 hospitals across Australia and is owned by Canadian private equity giant Brookfield.

The NSW auditor-general is investigating the performance of Northern Beaches Hospital, which also recently came under fire after 14-year-old Joshua Gill died just days after being discharged from mental health treatment.

The public should be confident that when they enter any public hospital they will receive safe and competent healthcare. It is vital there is a strenuous and swift examination of the Northern Beaches Hospital and the public-private partnership model to ensure patient care is never diminished, public confidence is restored and that no more lives are lost.

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