A Victorian coroner says the 2001 death of toddler Noah Souvatzis after a visit ton understaffed regional hospital should prompt health networks to check parents for their concerns.
The concerns of parents should be written into Victorian hospitals’ rule books, a coroner has said, after finding anfailed to appreciate a mother’s fears in the hours before her toddler, who had been discharged by a locum doctor, died.
Lorenz said parents know their children and how they typically present. She said parents’ concerns are valid markers for escalating treatment and urged the healthcare system to foster safer environments for parents to raise concerns and reduce preventable paediatric deaths. “At every stage of the investigation, they have shown remarkable fortitude, patience and integrity, and remained faithful to Noah’s memory.”Lorenz recommended hospitals include a section when a patient’s routine vital signs are checked where parents and carers are asked about their concerns.
“I don’t like this doctor but I have to trust,” Steph Souvatzis wrote in a text message before Noah was discharged. Noah was again sent to Wangaratta hospital and was eventually flown to the Royal Children’s Hospital, where he died. She found Bumford had only been in the emergency department for a matter of minutes, still completing a tour, when he was told to see Noah without being given any proper explanation about the hospital’s protocols and policies, including the low threshold option of referring sick children to the hospital’s paediatric ward.
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