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Carmel Sparke JUST minutes into his first shift , following
a hasty introduction to a rural hospital ’ s ED , a locum doctor diagnosed Noah Souvatzis with gastroenteritis .
Two days later , the toddler died of bacterial meningitis .
The locum , Dr Paul Bumford , says he has replayed his actions “ probably every day ” since the tragedy .
Now , Coroner Katherine Lorenz has delivered her report , which identifies failings in Noah ’ s care , not least Wangaratta Hospital ’ s use of locums .
Her conclusion was that they were being placed in positions they were never equipped to handle .
‘ Inadequate and rushed ’
In the case of Dr Bumford , the doctor
who first assessed Noah , she said he had the experience of a junior resident . Yet on 29 December 2021 , the day of the diagnosis , he had been placed second in charge of an ED that was being “ overwhelmed ”.
Lasting somewhere between four and 15 minutes , his “ inadequate and rushed ” induction included a brief tour but no written guidelines or policies , including information on the hospital ’ s low threshold for paediatric referrals .
Additionally , the senior doctor in charge of the ED “ did not appreciate
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‘ I ’ ve thought about this probably every day since it ’ s happened .’
— Dr Paul Bumford
[ the locum ’ s ] limited experience in the context of the role he was expected to perform ”.
The inquest was told that Dr Bumford had started the shift at the same time as Noah ’ s arrival : about 3.45pm .
The 19-month-old had been with his parents when he first became ill , vomiting and crying with a high fever , lethargic and unable to keep fluids down .
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Misdiagnosis
After Dr Bumford diagnosed viral gastroenteritis , Noah was monitored over the three-hour stay . Dr Bumford briefly discussed the case with the senior doctor before discharging the child .
Some two hours later , Noah ’ s parents took him to an urgent care centre . There , the on-call GP organised ambulance transfer back to
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AAP
Wangaratta Hospital for specialist paediatric care after speaking to an on-call paediatrician and commencing IV antibiotics on their advice .
On arrival , CT scans showed signs of meningitis . Noah ’ s condition deteriorated , and he required resuscitation and intubation before being flown to the Royal Children ’ s Hospital in Melbourne , where he was confirmed brain dead on 30 December .
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Bigger picture
The coroner found that Noah ’ s death
would have been preventable had he been given antibiotics when he first arrived at Wangaratta Hospital .
Dr Bumford told the inquest that , during the three hours the boy was at the hospital , his vital signs appeared to return to normal , but he “ wholeheartedly accepted ” meningitis and sepsis should have been considered .
“ I ’ ve thought about [ what I could have done differently ] probably every day since it ’ s happened ,” he told the Coroners Court of Victoria earlier this year .
“ I put far too much weight on these observations when I should have looked at the bigger picture .”
But the coroner said , without any real supervision , he had been “ too junior ” for the role he had been given , including the treatment of a complex paediatric category 2 patient , such as Noah .
Before his arrival at the hospital , Dr Bumford had spent one year working in an ED in the UK and around six months doing locum work in mixed EDs in Victoria , along with 18 months in a Victorian adult ED .
The coroner also criticised the senior doctor in charge for PAGE 6
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