Parents’ fight to save their toddler from a broken health system

WARNING: DISTRESSING CONTENT

When Ben and Steph Souvatzis arrived at Wangaratta hospital with their unwell toddler during a family holiday in 2021, they say they were confronted with chaos.

With the pandemic still in full swing, Ben Souvatzis said, disorganisation, panic and disagreements between staff were rife as he stood cradling semiconscious Noah in the waiting line of the emergency department.

Noah Souvatzis loved to smile and play at the park.

Hours after arriving, he said, he was handed back his 19-month-old floppy and pale, after a doctor on his first locum shift discharged the boy in what the family says was a worse state than the one in which he arrived.

“He looked awful. He had deteriorated. He could not keep his head up,” Souvatzis said. “He was so much worse than when he had gone in.”

The previously happy and healthy toddler was declared brain dead at the Royal Children’s Hospital in Melbourne days later, dying with bacterial meningitis after repeated attempts by the parents to get their son help at a string of healthcare providers in the state’s regional north failed.

The Coroner’s Court is now investigating the medical care Noah received and if his death could have been prevented.

Ben Souvatzis cradles his unwell son. Credit: Coroner’s Court of Victoria

At the court on Monday, Noah’s grieving parents called for accountability for what happened to their little boy, whose smiling face adorned a badge on their chests at day one of a week-long inquest into his death.

More than two dozen friends and family packed the courtroom to hear the tragic timeline of how the family’s Myrtleford holiday ended in the toddler’s death.

Lawyers for Northeast Health, which operates Wangaratta hospital, admitted for the first time that the care staff provided Noah was inadequate.

The court heard the Souvatzises made five trips to hospital or urgent care facilities in 48 hours to try to get their son help. They said that throughout the ordeal they faced under-resourced regional health clinics, including one which had run out of paracetamol and had broken equipment.

The parents first woke to find Noah unwell and vomiting about 3am on December 29, 2021. After initially improving, he began to deteriorate at 1.45pm and they called Nurse-On-Call, which advised them to take the boy to the Alpine Health Care Centre in Myrtleford. The centre was staffed by nurses with a doctor on call if needed.

They were told to drive to Wangaratta hospital, about 40 kilometres away, because it would be faster than waiting for an ambulance. But when the family arrived about 3.45pm, only one parent was allowed inside due to COVID-19 restrictions, forcing Ben Souvatzis to get updates via phone from his distressed wife.

The inquest heard that inside the hospital there were serious staffing and resource constraints due to staff being on leave and an influx of seasonal holidaymakers, which the family suggested had an impact on the level of care provided to Noah.

“I don’t like this doctor but I have to trust,” Steph Souvatzis wrote in a message shortly before Noah was discharged.

Ben and Steph Souvatzis leaving the Coroner’s Court on Monday.Credit: Justin McManus

The court heard the doctor who treated Noah at the hospital, Paul Bumford, was on his first locum shift and diagnosed the boy with gastro, despite his parents’ concerns that Noah’s behaviour was out of character for such an illness.

Bumford discharged the boy at 7.20pm, but as Noah’s condition worsened in the car ride home, the family drove to Benalla Urgent Care. Like the Myrtleford centre, it was staffed by nurses.

Noah was ultimately returned to Wangaratta hospital, and later flown to the Royal Children’s Hospital, where he died.

TIMELINE

December 29, 2021

• At 3am the family wakes to find Noah vomiting with a fever.
• At 1.45pm they call Nurse-On-Call, which advises them to visit the Alpine Health Care Centre in Myrtleford.
• At 2.30pm they arrive at Myrtleford.
• At 2.40pm the nurse at Myrtleford recommends they drive to Wangaratta hospital.
• At 3.45pm the family arrives at Wangaratta hospital.
• At 4.10pm Noah is first attended to by a doctor. His respiratory and heart rates are too fast and his temperature is high. He is given pain relief which he vomits up.
• At 4.50pm a rash appears on his chest and legs.
• At 6.30pm Noah’s vital signs improve.
• At 7.20pm Noah is discharged.
• At 9.30pm the family takes Noah to the Benalla Urgent Care Centre as he worsens.
• At 10.55pm Noah is assessed as being suitable to be taken by road transport back to Wangaratta hospital, but on the way he suffers seizures.

December 30

• At 1am the paediatric team at Wangaratta hospital determine Noah’s condition exceeds the facility’s capabilities and a specialist team is dispatched to take the boy to the Royal Children’s Hospital in Melbourne.
• At 6.45am Noah arrives in Melbourne.
• At 3.11pm he is declared brain-dead.

December 30

• Noah’s organs are donated and his life support is switched off.

In 2023, this masthead revealed the state’s hospital watchdog, Safer Care Victoria, had raised concerns about a shortfall of paediatric expertise among some doctors and nurses caring for children. The watchdog said it had become normal for clinicians to provide services to children “outside of their comfort zone”.

Noah in the car on the way to hospital.Credit: Coroner’s Court of Victoria

Outside court, Ben Souvatzis said the couple hoped the inquest would highlight the medical failures that occurred and prevent other children dying.

“Noah was a beautiful, gentle boy who loved cuddles and making others laugh and smile. He loved music and spending time outside, especially at a park where he would swing the day away,” he said.

“The most tragic part is that Noah does not get his chance at life. He deserved so much better.”

Dr Paul Bumford is to be called to give evidence on Tuesday.

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