The inquest into the death of five-year-old Rozalia Spadafora, who died in Canberra Hospital, appears to be set to reveal a series of "missed opportunities" to potentially save her life, a lawyer has said.
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Experts said the myocarditis, which she is believed to have died from, could have even been diagnosed up to 12 hours earlier.
The young girl was unable to stand by herself and had barely any appetite on the day she was waiting in the Canberra Hospital emergency department, her mother Katrina Spadafora has told the court.
The inquest will look at why the young girl, who had Influenza A, did not have her blood pressure taken in time, was moved into a lower acuity bed, and was given fluids when it may have worsened her condition, among other matters, counsel assisting Michael Fordham SC told the court on Wednesday.
Mr Fordham said the young girl was described as an "energetic, pocket rocket," and her death has devastated her family and friends.
When triaged at Canberra Hospital emergency department just after 7pm on July 4, 2022, Rozalia was put into category three - meaning she should have been looked at within 30 minutes.
She was first looked at by a clinician five hours later.
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Two emergency department doctors have different accounts of who was in charge of her bed after handover on July 5.
Test results were misinterpreted or ignored, and the young girl was moved from a resuscitation bed to a paediatric bed, Mr Fordham said.
'Window of opportunity'
An expert is expected to tell the court that hospital staff had a "window of opportunity" to escalate, stabilise and transfer Rozalia.
"Whatever chance of survival was available to Rozalia, it was lost," Mr Fordham said.
Whilst experts cannot say what the outcome would have been if things had been done differently, "she may have survived", he said.
Family and friends cried as Ms Spadafora, presented a slideshow of photos and videos of her daughter.
She called her "a beautiful, bright, bubbly spark of light" and a special little girl who loved life.
Rozalia was the "apple of everyone's eye" who was always singing and dancing, and was a "ray of sunshine in our lives".
"Never a day that would go by without her performing," she told the court.
'Difficult questions will be asked'
Mr Fordham said it was hoped that "for all who knew and loved Rozalia, and for all who treated and cared for her" there might be an improvement to how healthcare is delivered to children in Canberra.
"This is not an exercise in blame or vilification, however difficult questions will be asked and they will have to be answered. ... [We want to] reduce the chance of a similar event occurring in the future."
He said evidence suggested "a lack of cooperation and communication between paediatrics and ICU staff, and to a lesser extend, the emergency department teams".
"There are conflicts in the versions of events that occur between various witnesses in this brief of evidence."
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Coroner Ken Archer is presiding over the inquest.
"We are not dealing with mere words on pieces of paper, we are dealing with a tragedy [of a life ending]," he said.
"A young child of beauty and energy."
'A perfectly healthy little girl'
Rozalia had not been able to stand by herself for a day when she was made to wait five hours after triage at Canberra Hospital, her mother has told a coroners court.
Ms Spadafora said despite occassional ear infections, Rozalia was "a perfectly healthy little girl."
She was up to date with most immunisations but had not had an influenza vaccination that year.
On June 28, she saw GP Dr Khaleda Yesmin at the Kingston Foreshore Medical Centre because she had a fever to touch.
Ms Spadafora told the court Dr Yesmin said Rozalia had the beginnings of an ear infection, and was presribed antiobiotics, which seemed to work, Ms Spadafora said.
Rozalia, who turned five on July 4, had a birthday party the day before.
"She was not well. She was pretty much on the couch the whole day," Ms Spadafora said.
"That was concerning [for] me."
Ms Spadafora said Rozalia had puffy eyes, seemed tired and was pale.
She took the young girl to CAHMS at Canberra Hospital, and was given medication for a cough and swelling by a general practitioner.
On July 4, Rozalia was lethargic, quiet and still puffy, with a little cough, her mother said.
Rozalia had stopped walking on the morning of the July 4, and needed to be carried out of bed.
"I was concerned because she had not improved," Ms Spadafora said.
'Her heart is racing'
Ms Spadafora took her daughter back to Dr Yesmin at the Kingston practice. Rozalia was not speaking much and had little appetite.
She had not gone to the toilet, and ate very little.
Dr Yesmin recorded a temperature of about 37.4 degrees, Ms Spadafora recalled.
"Her heart is racing," the doctor said, according to Ms Spadafora.
Upon advice from Dr Yesmin, the mother took her daughter to the Canberra Hospital emergency department, arriving just after 7pm.
They went home first, dressing Rozalia in pyjamas at home as Rozalia had vomited in the car.
The wait to be triaged was about 20-30 minutes, Ms Spadafora said.
She wouldn't see a doctor until after midnight, the mother recalled.
The triage room was "about half full", the mother said, adding it wasn't the busiest she had seen it.
While waiting, Ms Spadafora and her mother held Rozalia, who was lying down.
The triage nurse took a temperature and a blood prick, the mother recalled.
They weren't told how long the wait was expected to be.
After triage, Rozalia lay on her grandmother's lap. She was "falling in and out of her sleep and very restless."
The three waited for two hours on armchairs. No one took the girl's observations or gave her any medication, Ms Spadafora said.
They then moved to the paediatric area about 10pm or 10.30pm. Someone took Rozalia's temperature and blood prick, and administered Panadol, Ms Spadafora remembered.
The nurse told the mother the girl's temperature was "spiking". They still did not know how long the wait would be.
Ms Spadafora was told to give her daughter 30ml of hydralite every 15 minutes through a syringe.
"She was able to keep that down until ... after we'd seen a doctor," the mother recalled.
Rozalia had to be held while being weighed, unable to hold herself up.
Before midnight, the mother remembers a doctor walked into the paediatric room before walking out, promising to return.
The doctor would see Rozalia about half an hour later. The mother remembers it as a 15-minute consultation.
"He just checked her ears, and her throat," Ms Spadafora said.
She does not remember the doctor taking Rozalia's blood pressure, something that counsel assisting Mr Fordham has indicated will be a key issue in the inquest.
Ms Spadafora was told to keep giving Rozalia hydralite as she was dehydrated.
More to come.
Lanie Tindale
I am City reporter at The Canberra Times. I previously covered health for the masthead, and was a trainee before that. I have written on courts, federal politics, breaking news, features and opinion. lanie.tindale@canberratimes.com.au.
I am City reporter at The Canberra Times. I previously covered health for the masthead, and was a trainee before that. I have written on courts, federal politics, breaking news, features and opinion. lanie.tindale@canberratimes.com.au.
