Ask parents about concerns, coroner tells hospitals after finding toddler’s death preventable

Asking parents about their concerns should be written into Victorian hospitals’ rule books, a coroner has said, after finding an understaffed regional hospital failed to appreciate a mother’s fears in the hours before her toddler, who had been discharged by a locum doctor, died.

Steph Souvatzis, hugging a white toy rabbit, sobbed in her husband’s arms as coroner Katherine Lorenz said on Tuesday that one-year-old Noah’s death from bacterial meningitis had been preventable.

Noah Souvatzis loved to smile and play at the park.

Lorenz said all hospitals should have safeguards in place to empower parents to raise and escalate concerns about their children, and their views should be sought. She noted the Souvatzis family made five trips to hospital or urgent care facilities in 48 hours to try to get help for their increasingly unwell son.

Noah was discharged from Wangaratta hospital after an inadequate review by an under-trained, junior locum doctor on his first shift at the understaffed regional healthcare provider, the coroner said.

Lorenz said parents know their children and what is normal for them. She said parents’ concerns were valid markers for escalating treatment and urged the healthcare system to foster safer environments for parents to raise concerns and to reduce preventable death of children.

The coroner praised the efforts of Noah’s mother and his father, Ben Souvatzis, in fighting for an inquest to be held after their concerns were consistently ignored while their son was sick.

Ben and Steph Souvatzis leave the Coroners Court on Tuesday.Credit: Luis Enrique Ascui

Lorenz noted the hospital’s post-death investigation failed to interview Noah’s parents or the staff involved in his care, which meant critical issues later uncovered during the coroner’s investigation were absent from any reports.

“I wish to convey my sincere sympathies to Noah’s parents, Ben and Steph, for their loss. Noah’s death was a heartbreaking and life-altering tragedy for them and their family and friends,” Lorenz said.

“I commend them both for courageously pursuing an inquest to ensure that Noah’s death had an appropriate and necessary public inquiry about the failings in care to Noah.

“At every stage of the investigation, they have shown remarkable fortitude, patience and integrity, and remained faithful to Noah’s memory.”

December 2021: Ben Souvatzis cradles his unwell son. Credit: Coroner’s Court of Victoria

Lorenz recommended hospitals include a section when a patient’s routine vital signs are checked in which parents and carers are asked about their concerns.

“Noah should not have been discharged [from Wangaratta hospital] in the circumstances,” the coroner said. “Had Steph been listened to ... Noah’s care should’ve been escalated. His death was preventable.”

An inquest in April heard Noah and his family had been holidaying in the Myrtleford area when his parents woke to find him unwell and vomiting about 3am on December 29, 2021. Later that day, they phoned Nurse-On-Call and were told to take Noah to the Alpine Health Care Centre in Myrtleford.

Once there, they were told to drive to Wangaratta hospital, almost 40 kilometres away, as there were delays in getting an ambulance. When the family arrived at the hospital about 3.45pm, COVID-19 restrictions meant only one parent was allowed inside, which forced Ben Souvatzis to wait for updates on his phone from his distressed wife.

“I don’t like this doctor but I have to trust,” Steph Souvatzis texted before Noah was discharged.

The doctor who treated Noah there, Paul Bumford, was on his first locum shift and diagnosed the boy with gastro. Bumford discharged the toddler at 7.20pm after providing what Lorenz later found was “grossly inadequate” care amid a “serious error in clinical judgment”.

As Noah’s condition worsened on the car ride home, the family drove to Benalla Urgent Care but, like the Myrtleford centre, it was staffed by nurses.

Noah became unwell on a family holiday in the Myrtleford area in December 2021.

Noah was again sent to Wangaratta hospital and was eventually flown to the Royal Children’s Hospital, where he died on December 31, 2021.

During the inquest, Noah’s parents recalled being confronted by chaos when they arrived at Wangaratta hospital with him during the pandemic.

Ben Souvatzis told the coroner he was surrounded by disorganisation, panic and disagreements between staff as he stood cradling a semiconscious Noah in the waiting line of the emergency department.

He said that hours after arriving at the hospital, he was handed back his son, floppy and pale, after the junior doctor discharged the boy.

The family maintains Noah was in a worse state than when they arrived.

In recording her findings on Tuesday, Lorenz found Noah’s death could have been prevented if he had been given more substantial care, including antibiotics, when he first arrived at Wangaratta hospital.

She found Bumford had been in the emergency department for only a matter of minutes and was still being shown around when he was told to see Noah without being given any proper explanation about the hospital’s protocols and policies, including the option of referring sick children to the paediatric ward.

The coroner was particularly critical of the senior doctor in charge, Doug Devereux, whom she found should have thoroughly assessed Noah knowing it was Bumford’s first shift.

Dr Paul Bumford leaves the inquest in April.Credit: Jason South

Outside court on Tuesday, Steph Souvatzis cradled and kissed her new baby boy and expressed happiness at the inquest outcome to friends and family who had filled the court in support.

“Ben and Steph have felt for years they haven’t been heard,” the family’s lawyer, Paul Lamb, told the coroner.

“From the emergency department at Wangaratta hospital until this inquest, they fought hard to get here. And they’re very grateful [to your honour].”

A spokesperson for Northeast Health Wangaratta, which runs the hospital, said it was committed to implementing further improvements upon reviewing the coroner’s findings.

“NHW accepts that Noah did not receive the care he should have, something that rightly weighs very heavily on us as a health service,” the spokesperson said.

The Morning Edition newsletter is our guide to the day’s most important and interesting stories, analysis and insights. Sign up here.