Doctor’s regret over treatment of toddler who died after being discharged

A regional doctor who discharged 19-month-old Noah Souvatzis from an understaffed emergency department says he is devastated by his death and wishes he had escalated the toddler’s care.

Paul Nicholas Bumford told a coroner investigating Noah’s death it was his first-ever locum shift at Wangaratta hospital when Noah arrived on December 29, 2021, and he believed the boy had gastro.

Noah Souvatzis.

He discharged Noah 3½ hours later into the care of his parents, who returned him to the hospital hours later. Noah was then flown to the Royal Children’s Hospital, where he died with bacterial meningitis.

On Tuesday, Bumford said that with the benefit of hindsight he wished he had asked a more senior doctor to assess the unwell child, done further checks after Noah continued to vomit during his discharge from hospital, and referred him to the paediatric team to keep him under observation for longer.

“Given his condition had improved, I felt it was reasonable to discharge him,” the doctor told the inquest. “I am devastated at [the] outcome.”

Bumford said he wholeheartedly accepted meningitis and sepsis should have been things he was on alert for. “That was a huge error on my part … Obviously there have been a lot of failings on my part,” he said.

“I’ve thought about [what I could have done differently] probably every day since it’s happened,” Bumford continued. “A big problem for [the parents] was me not listening to them … I’ve thought about that a lot.”

Other witnesses told the Coroners Court that the regional hospital was plagued with staffing shortages, long ambulance waiting times, internal conflict and a lack of experience and seniority among employees.

The region was also experiencing a holiday boom with families flocking to the area after 18 months of coronavirus lockdowns, they said.

Dr Paul Bumford outside court.Credit: Jason South

“It had been pretty dire,” triage nurse Read Moreland said with tears in her eyes. “I do still remember that day.”

A coroner is investigating the medical care Noah received and if his death could have been prevented.

Moreland, the triage nurse working on the day Noah was first taken to Wangaratta hospital, described the days leading up to his arrival as being a “shitstorm” and recalled she had texted others to say: “I don’t know we’re all going to survive ... over the next few weeks/months.”

She told the court everything had been controlled during lockdowns, but once things opened up, there were no extra resources provided to help manage the increasing workload from holidaymakers.

Moreland noted it was common to hear patients had tried to get ambulances but were told it would be faster to drive themselves, as occurred in Noah’s case, “which is frightening for those people and us sometimes”.

Noah’s parents, Ben and Steph Souvatzis, who were holidaying in the area, previously told the court they were forced to repeatedly take their increasingly unwell son to a string of regional health services only to be mostly turned away.

After first arriving at Alpine Health Care Centre in Myrtleford about 2.30pm the family were sent to the Wangaratta emergency department, arriving about 3.45pm. They were then discharged, with what Ben Souvatzis said was a sicker child than they arrived with, about 7.20pm.

During his evidence, the father said he recalled that panic and disagreements between staff were rife as he stood cradling semi-conscious Noah in the waiting line of the emergency department.

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”.

The inquest into Noah’s death continues.

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