A coroner has reassured an emergency doctor who sobbed and apologised during an inquest.
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A lawyer for the ACT government was stopped from asking Dr Kirsty Dunn questions on Tuesday as the doctor gave evidence at the coronial inquest of five-year-old Rozalia Spadafora.
Coroner Ken Archer said an internal document allocating doctors to beds was "confusing", and understood why medical staff were confused.
Bed confusion
On Monday, another emergency doctor, Dr Amy Ting, told the court she had interpreted a day sheet document as giving Dr Dunn responsibility for Rozalia.
Dr Dunn said she interpreted the day sheet as giving Dr Ting responsibility for the little girl because of a handwritten addition.
When counsel assisting Michael Fordham SC asked Dr Dunn whether she understood the day sheet to give her responsibility for Rozalia, she became emotional.
"No, I'm sorry, I did not," she cried.
"I'm so sorry, I feel terrible."
Dr Dunn said while the day sheet listed assigned beds to different doctors via geographic location, in practice they were allocated differently each day.
Dr Dunn said the hospital emergency department still uses this day sheet format to assign beds.
Government lawyer questions witness
Lawyer for the ACT government, Maria Gerace, asked Dr Dunn a long series of questions about the day sheet.
Ms Gerace asked if Dr Dunn agreed that "in fairness to the staff, the document should not be inconsistent" and "this document had to be clear and succinct".
However, Dr Dunn insisted the sheet was not consistent or clear, and the coroner appeared to agree.
"It changed so often there was a lot of confusion," Dr Dunn said.
At one point during the inquest Ms Gerace and counsel assisting the coroner, Michael Fordham, appeared to have a tense exchange.
When Mr Archer asked Dr Dunn to leave the room so he could talk to the lawyers, the doctor fled in tears.
Mr Archer told Ms Gerarce that continuing her point was not helpful, and it seemed that Dr Ting and Dr Dunn had "interpreted the document in different ways".
"It seems to me that the document is internally inconsistent and people approached it in different ways," Mr Archer said.
"That seems to have contributed to a misunderstanding on the day."
When Dr Dunn returned to the court room, Mr Archer reassured her.
"The last thing we want is for these proceedings to cause you unnecessary distress," he said.
"There was a legitimacy for confusion.
"This has caused you great distress, I'm sorry for that."
The coroner also said his job was to decide how significant particular issues were, and the allocation of responsibility of beds on the morning "may not have been the most important issue".
Several witnesses have said that the emergency department physicians were not primarily responsible for the ongoing care of Rozalia on the morning of July 5.
'Sickest child'
Dr Dunn also told the court Rozalia was so sick that the night paediatric emergency doctor, Dr Tze Hoa Wong, "shuddered" at her name.
Dr Wong was present during the handover from night to day staff.
"He did like an involuntarily shudder as if someone had chilled him when they started to talk about Rozalia," Dr Dunn said
"He said it was the sickest child he'd looked after and it had distressed him."
Dr Dunn said she was told Rozalia had turned a corner following treatment, which is why she told a nurse the little girl could move to a lower acuity bed.
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Two witnesses expected to give evidence on Tuesday did not appear.
The court was told they wanted time to seek separate legal representation.
Mr Archer addressed the Spadafora family on Tuesday afternoon.
"It's been a fairly confronting sort of experience," he said.
"I think it has been for everybody in the room, frankly.
"Everybody feels for you and your loss."
The inquest is expected to continue on December 5.
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