Unreasonable delays in the treatment of a five-year-old girl at the Canberra hospital ultimately led to her death. That's the finding of the ACT coroner who examined the events leading up to the death of Rozalia Spadafora in 2022. The little girl died in the emergency department after 24 hours during which there were multiple missed opportunities to save her.
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00:00It was meant to be a day of celebration, but Rosalia Spadafora's fifth birthday would be her last.
00:09The girl, described as a bubbly spark of light, woke up lethargic, without her usual appetite.
00:15After multiple GP visits, her family was left with nowhere else to go but the emergency department.
00:22Rosalia arrived at the hospital at 7pm on the 4th of July.
00:27She was triaged at 7.40 and should have been seen by a doctor within half an hour.
00:32But that didn't happen until after midnight.
00:35Rosalia had an ECG shortly before 7am. The result was misread.
00:41A test result indicating damage to the heart lining was available shortly before 10am,
00:47but wasn't made clear to the treating doctor until after midday.
00:52By the time staff were preparing to transfer Rosalia to Sydney, more than 24 hours after she'd first presented,
00:59she was too unstable for the journey.
01:02The coroner described those delays as unreasonable.
01:06I find that the delay in Rosalia's diagnosis and the failure to provide Rosalia with appropriate treatment
01:12in a timely manner meant that any opportunity Rosalia may have had for survival was lost.
01:18Rosalia's family filled the courtroom today, her mother still wondering what more she could have done.
01:25Over two days, nine consultations with health practitioners, my mother and I tried to get my daughter the help she needed.
01:33We failed at every step and watched her slowly die in front of us.
01:37We're confident with the changes that we've introduced over the last couple of years
01:43and the gains that we've already seen that we've made, this would not happen under the same circumstances today.
01:49But Mr Pfeffer wouldn't be drawn on whether anyone would lose their job.
01:54Ultimately, I'm the leader of the health service and this is my accountability.
01:59The health minister said she would also write to the family expressing her and the ACT government's condolences.
02:06Canberrans are entitled to expect the very best care at Canberra Health Services, she said.
02:11I acknowledge that the care provided to Rosalia tragically did not meet those standards.
02:17My family cannot have any confidence in CHS or this government to safely look after our children.
02:22The findings came on the same day as the release of updated data on emergency department wait times,
02:28which appear to show some improvement in the ACT.
02:32The coroner said Rosalia's death served as a reminder of the potential consequences of delays in the ED.
02:39I'm here so no other mother will suffer my unrelenting grief and guilt.
02:44Grief that will undoubtedly remain forever.