Are Canberrans held hostage to ACT’s only tertiary hospital, as Rozalia Spadafora’s mother suggests?

Rozalia Spadafora’s mother didn’t mince words as she held back tears, speaking directly to Canberra Health Services after the coronial inquest into her daughter’s untimely death.

“I would be grateful to the coroner for telling me if there was anything more I could have done for my daughter,” Katrina 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.” 

Rozalia presented to the Canberra Hospital on her fifth birthday.

Twenty-seven hours later, she was dead.

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What led to the young girl’s death was nothing more or less than a litany of errors, leaving her mother and Canberra wondering whether if even one small thing changed about the care provided on the day Rozalia walked into the hospital, she might still be alive.

If the doctor who was supposed to be looking after her noticed earlier that Rozalia had symptoms of myocarditis.

If the clinical initiative nurse (CIN) nurse who was supposed to be rostered on the day she presented was there.

If she had been taken to a Sydney hospital when at midday the next day Ms Spadafora was told that the muscles around her daughter’s heart were inflamed and she should be transported.

If, at 7pm, more than 24 hours after she first arrived at Canberra Hospital, Rozalia had been prepared for transport to Sydney.

Are Canberrans, often with no other choice but to present to Canberra Hospital, at risk of the same fate?

Are we hostage to the failures of the only tertiary hospital in the region, as suggested by Rozalia’s mother?

Wait times major factor in five-year-old’s death

If Rozalia was taken to Canberra Hospital today, would things have played out the same way?

Canberra Health Services doesn’t think so.

“We’re confident with the changes that we’ve introduced over the last couple of years and the gains that we’ve already seen made, this would not happen again under the same circumstances,” chief executive Dave Peffer said to members of the media after the findings were handed down yesterday.

“We are a vastly improved, a vastly different healthcare service to what we were two and a half years ago.”

Coroner Ken Archer clearly pointed to the time it took to provide Rozalia with adequate care as one of the many Canberra Health Services failures without which the child might still be alive.

Canberra Health Services failed to meet all but one of its targets relating to emergency department wait times last financial year.

The service’s latest annual report shows its target was to treat 100 per cent of category one patients — that is, those with a life-threatening condition — within the clinically recommended time frame but failed to in 1 per cent of cases.

Category three or urgent patients, the category eventually given to Rozalia before her death, are supposed to be seen within 30 minutes. The service only managed that in 51 per cent of cases, well below the 75 per cent target.

Lance Lasersohn, clinical director of anaesthetics for Canberra Health Services, said the rostering at CHS had changed since Rozalia’s death.

He added there had been “massive changes” to the hospital.

One of the shortfalls on the night of Rozalia’s death highlighted by the coroner was the lack of a CIN, a specialist nurse who is supposed to have a 24-hour presence in the hospital.

For some reason, he said, a CIN nurse was not rostered overnight, and their whereabouts earlier in the evening remained unclear.

The coroner also recommended the CHS handover processes be reviewed, something Mr Peffer said had already been looked at.

The simple disappearance of a post-it note with crucial details about Rozalia’s condition is one failure out of many that prompts the agonising question of whether its prevention could have saved her life.

Dr Lasersohn said that failure, too, wouldn’t happen today.

No closure in the loss of a child

CHS said it would also be accepting all of the coroner’s recommendations, which included adequate staffing of the emergency department and to actively promote influenza vaccinations among young children, the usually treatable flu Rozalia had contracted.

This, understandably, is still not enough for Rozalia’s family.

Ms Spadafora has called for a royal commission into Canberra Health Services, something that has been supported by the Canberra Liberals.

“We will advocate for a royal commission into CHS and Canberra Hospital for the sake of the community and its wellbeing.”

The chief executive of CHS wouldn’t be drawn on whether the Spadaforas would receive compensation for their daughter’s death.

“Rozalia was the best and we can never move on from losing her,” Katrina Spadafora said through tears.

“Nothing will ever take this pain away and we have to try and move forward but we can’t.

There is no real way to know the point of no return in the tragedy that befell Rozalia Spadafora, out of the extensive list of errors, miscommunications and poor decisions, outlined extensively in the coroner’s report.

Canberra’s health services must now make sure no-one else is subject to such a systemic and tragic failure.