Grieving parents call for urgent inquiry into Northern Beaches Hospital after son’s ‘preventable’ death
Toddler Joe Massa had his whole life ahead of him. His parents Elouise and Danny claim a systemic failure by Northern Beaches Hospital led to his “cruel and preventable” death.
NSW
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Two-year-old Joe Massa had his whole life ahead of him yet his parents Elouise and Danny claim a systemic failure by Northern Beaches Hospital led to his “cruel and preventable” death.
The North Balgowlah couple is now calling for an urgent inquiry into the hospital – which is run under a public-private partnership – after their “cheeky and gentle” son died on September 14 last year following a misdiagnosis and critical delays in treatment.
The Massas had called an ambulance to take their little boy to the hospital’s emergency department around 6.30am on September 14, 2024, after he awoke with a pounding heart and in agony. He had vomited once the previous night but aside from that had been well.
Once at the hospital – despite a dangerously high heart rate and visible deterioration – Mrs Massa said Joe was triaged as a category three patient – when he should have been put in the category two red zone.
“His heart rate was pounding, he was clammy to touch though he had no fever, he was really agitated and in so much pain,” Mrs Massa said.
“The nurse wrongly classified him – he should have been category two which is those who have an imminently life-threatening condition and need to be seen by a senior doctor within 10 minutes, have their vitals monitored every 15 minutes.
“If the standard protocol had been followed, it would have saved his life.”
It was later determined that Joe was suffering from significant hypovolemia – a condition that occurs when the body loses too much fluid – caused by an easily treatable infection in his gut.
The standard treatment would be IV fluid resuscitation – yet Mrs Massa’s repeated pleas for staff to hook her son up to an IV drip were ignored.
“I asked for him to be put on a drip three times – we now know it would have saved him as it would have stabilised his body so doctors could have figured out what was going on,” she said.
Despite the ED being virtually empty – just two other patients – Mrs Massa and her son were denied a bed for two-and-a-half hours. Joe’s heart rate was spiking – from 163 beats per minute at the point of triage to 197 BPM 20 minutes later.
“I asked for a bed and was told no – so I sat on a chair with Joe in my arms with a syringe to give him electrolytes as the ED nurse had put his condition down to gastro,” she said. “I sat in the middle of ED with empty beds all around me, but it took hours for Joe to get access to one.”
Dispute his agony, Mrs Massa said Joe was also not offered any pain medication – even when he was given a bed, he was not connected to a drip nor any monitoring technology.
‘HE LOOKED LIKE A LIMP RAG DOLL’
“The staff ignored critical warning signs – he was declining rapidly, his eyes were sunken, his lips had started to turn blue, his skin was mottled, he was going in and out of consciousness,” she said.
“He looked like a limp rag doll. Then his eyes rolled into the back of his head and I started screaming and yelling ‘he’s gone blind’.”
Joe was finally taken to a resus room around 10.30am with his mother. That’s where Mr Massa found them – with no staff – when he arrived, having been looking after the couple’s two other children.
“They’d just pushed Joe’s bed in there and left them – it was unfathomable,” Mr Massa said.
Then the worst happened. At 10.47am – in the room unattended by medical staff – Joe suffered a catastrophic cardiac arrest.
“He turned his head and a tear rolled out of his eye down his cheek,” Mrs Massa said. “He died in that moment.”
It was then that a “circus” of staff entered the room, and the distraught parents could only watch on as Joe underwent CPR for 29 minutes.
The prolonged resuscitation effort led to irreversible brain damage and while he was transferred to Sydney Children’s Hospital, he was pronounced brain dead two days later with the Massa’s forced into a terrible decision.
“We had no choice but to cradle him in our arms, unplug the life support and leave two days later without him,” Mrs Massa said.
A Serious Adverse Event Review Findings Report into the incident acknowledged that there was a delay / failure by the hospital to recognise deterioration.
“The SAER team accept that an earlier recognition of the deteriorating child may have provided an opportunity for early escalation and resuscitation with potential prevention of the cardiac arrest event,” the report stated.
The team found there was a failure from staff to recognise and respond to a heart rate in the red zone particularly in the absence of fever; a failure to respond to parental concern and a failure to respond to clinician concern as per internal escalation processes.
During the SAER investigation, it was identified that two clinicians’ professional practice was not to the expected standard.
Among its recommendations, the review suggested a retrospective review of assigned triage category appropriateness and a review of the hospital’s electronic systems.
However the bereaved parents want more.
“We want an independent and public review into serious malpractice at Northern Beaches Hospital’s emergency department to prevent further tragic losses,” Mrs Mass said.
“We want an awareness campaign around the REACH protocol (which allows caregivers and patients to escalate concerns) so parents and others concerns are not ignored.
“We want urgent IT system updates at Northern Beaches to ensure there are alerts for at-risk patients if human error occurs.
“And we want the state government to evaluate the public private partnership with Northern Beaches Hospital as we believe they put profits before patient care.”
A Northern Beaches Hospital spokesman said the hospital offered “its deepest condolences to the Massa family for the loss of their son, Joe”.
“We recognise Joe’s death has caused unimaginable heartache and grief for the family,” the spokesman said.
“We have met with the family to apologise and hear directly about their tragic experience and to discuss the findings of the Serious Adverse Event Review.
“We will continue to support the family in any way that we can as we implement the improvements identified in the review, including improvements around triaging processes and internal escalation processes.”
On Thursday morning NSW Premier Chris Minns said the Massa family deserve “answers” about why their son died at the hands of hospital staff.
“Can I just say it was clearly a terrible, terrible mistake,” Mr Minns said.
“I can only imagine the pain they’re going through. They’re after answers for their own family, but they’re after answers to ensure that this doesn’t happen again to anybody else.
“I’ll do anything we can to ensure they get answers as to what happened, we won’t rule anything out … we take this incredibly seriously and I’m profoundly sorry this has happened, it’s absolutely heartbreaking.”
Mr Minns said said the case was “of the highest priority”, however he would not comment on the two nurses who were found to have mistreated Joe in the independent review – and are still working in the health system.
“I can’t speak to that specifically. I really need to understand the circumstances of the case,” he said.
Health Minister Ryan Park said he has asked the state’s Chief Paediatrician to review the tragedy, and had spoken with the Secretary of NSW Health to understand actions being taken in response to it.
“My heart goes out to Elouise and Danny – this is a terrible tragedy,” he said.
“As the Minister for Health, this is among the worst possible things that can happen in our health system – a young child who should be with us is no longer alive.
“I have had the opportunity to speak with the parents directly – I never want any parent to go through this.”
Mr Park confirmed Northern Beaches Hospital had accepted all recommendations of the Serious Adverse Event Review, and he’d made it clear that they needed to be implemented in full and as quickly as possible.
In 2014, the then Liberal state government entered into a Public Private Partnership with Healthscope to deliver the Northern Beaches Hospital, which officially opened in late 2018. The hospital provides free public patient services as well as a range of services for private patients.
“This incident raises serious questions about privatisation and this type of model. I note there is an ongoing Auditor-General’s Inquiry into the effectiveness of these services,” Mr Park said.
“I want to get to the bottom of this.”
Contact lisa.wachsmuth@news.com.au
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