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Coroner finds delay in treating five-year-old Rozalia Spadafora left her with no opportunity for survival
Rozalia Spadafora, who died at Canberra Hospital the day after her fifth birthday in July 2022. (ABC News: Harry Frost)
In short:
The ACT Coroner has handed down his findings following an inquest into the death of five-year-old Rozalia Spadafora at the Canberra Hospital in 2022.
Rozalia died from myocarditis more than 24 hours after presenting to the hospital's emergency department.
What's next?
The coroner has made adverse findings against the ACT government and five doctors, as well as making four broad recommendations.
The ACT Coroner's Court has found the delay in treating five-year-old Rozalia Spadafora at the Canberra Hospital in 2022 left her with no opportunity of survival.
On her fifth birthday, Rozalia's family took her to the emergency department on the advice of their GP as she was becoming increasingly unwell with what was thought at the time to be an ear infection.
What followed was a long ordeal, during which Rozalia was left waiting for hours with what the family described as only the most cursory of examinations.
It was 12 hours before medical staff confirmed she had an abnormal heart rate, an enlarged liver, and had tested positive for influenza A.
Rozalia Spadafora died 27 hours after she was admitted to the Canberra Hospital. (Supplied)
Twenty-seven hours after presenting at the emergency department, Rozalia went into cardiac arrest and died from what was believed to be the heart condition myocarditis.
The Spadafora family told the ABC they were "disgusted" by the way they had been treated by the hospital.
Coroner Ken Archer released his findings on Friday, saying there would have been a much better prospect of stabilising Rozalia and transferring her to a hospital in Sydney had she been diagnosed earlier in the day.
Rozalia's mother Katrina and other family members have given harrowing accounts of the way she was treated at Canberra Hospital. (ABC News: David Sciasci)
Nurse position should be 24 hours
Magistrate Archer found that Rozalia had a rare "and potentially lethal" condition that caused inflammation of the muscles around her heart.
"Her best chance of survival was for her condition to be properly diagnosed and for her to be airlifted for proper treatment in Sydney," he told the court.
"It took too long for her condition to be diagnosed."
The coroner found Rozalia was not seen by a doctor for more than five hours, when she should have been seen within 30 minutes based on her triage category.
Coroner Ken Archer handed down his findings in a packed ACT Magistrates Court on Friday. (ABC News: Michael Barnett)
He also found that an electrocardiogram test was misread, myocarditis symptoms were not properly assessed, and that there was not a "cohesive and coordinated" response between different areas of the Canberra Hospital.
The court heard the hospital used what's known as a clinical initiative nurse (CIN) to assess patients who present to its emergency department.
But the coroner said it was not possible to find out why that nurse process did not operate effectively when Rozalia presented to the hospital.
Live Moment
Look back on the coronial inquest findings into the death of five-year-old Rozalia Spadafora.
That's all from us
For some reason, he said, a CIN nurse was not rostered overnight, and their whereabouts earlier in the evening remained unclear.
The coroner has made a recommendation that Canberra Health Services (CHS), who operate the Canberra Hospital, should require a CIN position to be filled 24 hours a day, and should implement a policy that prevents it from being subsumed into the emergency department during busy periods.
Katrina Spadafora (right) arrived to the ACT Coroner's Court with a large group of family and friends to hear the coroner's findings. (ABC News: Michael Barnett)
The coroner made three other broad recommendations, including that CHS review the parts of its record system and handover processes between medical staff.
Coroner Archer also made adverse findings in relation to the ACT government and four doctors.
They were provided a copy of the coroner's findings in October and given a chance to respond.
Two of those doctors responded, and Coroner Archer said he made small changes to the wording of his findings.
Mother says she feels guilt about Rozalia's death
Loading...After the findings were handed down, Rozalia's mother Katrina Spadafora said she had felt guilt since her daughter's death and pondered if she should have been more aggressive and assertive in the hospital while her daughter was deteriorating.
"I would be grateful to the coroner for telling me if there was anything more I could have done for my daughter," Ms Spadafora said.
"I would have been grateful because, like any other person in Canberra and its surrounds, we are held hostage by the Canberra Hospital and are forced to play Russian roulette.
"And, in Rozalia's case, the chamber was loaded."
Ms Spadafora said she had called for the inquest so no other mother would suffer the same "unrelenting grief and guilt" she experienced.
"Rozalia was the sun who gave life to my family in Canberra, Griffith, Sydney, and Italy," she said.
"Since Rozalia's passed my family have been lost.
"We have no answers for why she died; no answers this inquest brings will bring my daughter back."
Ms Spadafora said the family would be advocating for a Royal Commission to be held into Canberra Health Services.
"Given everything my family has been through, and the repeated failure of clinical governance by CHS, my family cannot have any confidence in CHS or this government to safely look after our children," she said.
"We will advocate for a Royal Commsion into CHS and Canberra Hospital for the sake of the community and its wellbeing."
Ms Spadafora said she would never get closure for the death of her daughter, and the coronial inquest had not changed that.
She said nothing would take the pain of losing Rozalia.
Ms Spadafora added that her daughter's decline in condition was obvious to her family and members of the public, so should have been recognised by health service staff members.
"The nurses and doctors were wilfully blind to my daughter's condition," she said.
Evidence suggests Rozalia Spadafora died of myocarditis as a consequence of Influenza A. (Supplied)
Rozalia's death was not legally required to be investigated by a coroner, the court has heard, but the inquest was by request of her family.
Coroner Archer said coronial inquiries usually have the goal of not doing more harm to affected families, but he said he wasn't sure that goal could always be achieved.
He said Rozalia's family had to endure a "minute by minute" forensic analysis of why their daughter died.
"I can only imagine their pain," he said.
He commended her family's courage to advocate on behalf of their child.
Health workers 'don't go to work to harm'
After the findings were handed down, CHS admitted to failings in its care for Rozalia, saying the agency was "deeply sorry" that the "systems and processes of CHS let Rozalia and her family down".
In a statement, CHS said the care provided to Rozalia did not meet their standards.
Speaking outside court, CHS chief executive Dave Peffer said Rozalia's death had sent an "absolute shock-wave" through the health service.
"Every team member is still feeling it," Mr Peffer said.
"This was such a tragic, sad outcome — so hard for the family."
Canberra Health Services CEO Dave Peffer said Rozalia's death sent an "absolute shock-wave" through the agency. (ABC News: Michael Barnett)
CHS said it "fully" accepted the findings of the coroner, and had already implemented changes to improve the care offered to children.
"This includes hiring additional specialist staff, expanding services, more training for our team members, ensuring clearer processes are in place, making structural improvements at our facilities and having clearer escalation points for our health workers," the CHS statement said.
Senior CHS staff member Professor Lance Lasersohn said Rozalia's death impacted everyone at the department.
"No health worker goes to work thinking they want to harm people," Professor Lasersohn said.
"Rozalia's death has made a massive impact on everyone from the clinicians to the executive."
In a statement ACT Health Minister Rachel Stephen-Smith offered condolences on behalf of the government to the Spadafora family, and acknowledged Rozalia did not receive the standard of care expected of CHS.
"Since Rozalia's death, Canberra Health Services has worked to improve the way critically unwell children are cared for," she said.
"This has been an extremely challenging time for Rozalia's family and I hope the release of the Coroner's report brings some measure of closure."