Grant and Naomi Day have been campaigning for change since the death of their six-month-old son Kyran on October 22, 2013, after he was diagnosed with gastroenteritis, when he was in fact suffering from a bowel obstruction.

A coronial inquest was held in May, and on Wednesday the findings were handed down which included a range of recommendations for the health and ambulance services which could be implemented statewide.

‘’We started this journey three years ago because we wanted to make sure there was change ... so anyone going to a NSW hospital could do so with trust in the medical system,’’ Mr Day said.

‘’It's bittersweet but we welcome the recommendations as we know Kyran's legacy will now live forever.’’

Kyran’s family continually questioned the initial diagnosis on October 19, 2013, but the correct diagnosis was only made 20 hours after he first saw a doctor. The Days’ then had to wait four hours for an ambulance to take him to Sydney children’s hospital.

During the transfer, Kyran lost consciousness and the ambulance was diverted to Shellharbour Hospital where he suffered several cardiac arrests before he was flown to Sydney for surgery. He died on October 22.

Deputy State Coroner Magistrate Teresa O’Sullivan found that Kyran died ‘’after those treating him failed to detect … and respond to his condition in a sufficiently timely manner’’.

She recommended that NSW Health Minister Jillian Skinner examine the policy and training programs since activated by the Illawarra Shoalhaven Local Health District – to see if they should be implemented statewide.

She also recommended NSW Ambulance Service advise the coroner as soon as the Medical Priority Dispatch System was implemented. The service was also advised to consider more effective ways to communicate the qualifications of paramedics, and the ways calls were processed, to hospital staff.

ISLHD chief executive Margot Mains said the district had implemented a range of measures after an internal investigation. This included staff training as well as the employment of an additional staff specialist paediatrician, two junior doctors and a clinical nurse specialist at Shoalhaven Hospital.

‘Vision for Life’ technology had been installed in district hospitals, to provide vision and sound of unwell infants to specialists elsewhere.

‘’We will continue to support the family as they work with NSW Health agencies to ensure the lessons learned from this tragedy can make a real difference to the care of our youngest patients.’’

‘’Our internal investigation, together with HCCC investigations, delivered recommendations and lessons, mainly around staff education and training and transfer processes, which have now been implemented by Shoalhaven Hospital,’’ Ms Mains said.

Ms Skinner said NSW Health, including NSW Ambulance, would also carefully consider all recommendations.

‘’Kyran’s death was tragic. I extend my condolences to his parents, Grant and Naomi, and their family who have been working closely with the NSW Clinical Excellence Commission on strategies to ensure the immediate investigation of concerns raised by loved ones if a patient’s condition deteriorates in hospital,’’ she said.

‘’In particular, the family and the CEC are discussing how to extend the existing REACH program (Recognise, Engage, Act, Call and Help Is On Its Way) to hospitals across the state.

‘’As a result of the family’s advocacy, Kyran's name and photograph will be included on information posters and brochures which will be available to families of all paediatric patients on admission to hospital.

‘’Kyran’s mother will also tell his story in a training video for NSW Health staff.’’

A NSW Ambulance spokesperson added that the organisation’s ‘’progress in meeting the two new protocols recommended by the coroner is well advanced’’.

EDITORIAL

Grant and Naomi Day have had to endure something no parent should go through.

But they have also done what many others may not have been able to do in light of such unbearable pain and loss as well.

Grant and Naomi had to watch on as their baby boy died after a misdiagnosis at the Shoalhaven Hospital in 2013.

They knew they had to do something about the death of their baby Kyran so that other parents following in their footsteps did not suffer the same fate.

From the day they lost Kyran they began campaigning for change in the health system.

On Wednesday the New South Wales’ Deputy State Coroner Magistrate Teresa O’Sullivan announced the findings into Kyran’s coronial inquest.

What followed was a wide-ranging series of recommendations for change in the hospital system.

‘’We started this journey three years ago because we wanted to make sure there was change ... so anyone going to a NSW hospital could do so with trust in the medical system,’’ Kyran’s father Grant said.

‘’It's bittersweet but we welcome the recommendations as we know Kyran's legacy will now live forever.’’

The coroner’s report makes special mention of Kyran’s parents and of Naomi’s address to the inquest.

“She spoke beautifully about Kyran and the pain she and Grant continue to experience; I was very moved,” Deputy State Coroner Magistrate Teresa O’Sullivan stated.

“Naomi and Grant attended court every day of this inquest along with Kyran’s grandparents. 

“Naomi and Grant have known each other since they were 13 years old. 

“Grant’s mother and Naomi’s mother both worked as nurses at the Shoalhaven District Memorial Hospital and are close friends. 

“Kyran’s death has been extremely traumatic for the whole family. 

“I offer the family my heartfelt condolences. 

“I thank them for their enormous contribution to this inquest.”  

What a great sacrifice to make and a gift to give after the loss of your child.

As tragic and as sad as it is, the hope this will lead to positive change in the health system is something to be positive about.

It seems Kyran Day will have a long lasting legacy after all.