As emergency department doctor Babak Tajvidi concluded his evidence before a coronial inquest in Nowra into the toddler’s death in March 2016 he addressed the dead boy’s parents saying he was “sorry” and had “made a mistake”.

During his evidence he conceded the Troy “most likely” already had sepsis, which ultimately killed the toddler, when he first presented to hospital just after 10am on March 21, 2016.

Dr Tajvidi said in hindsight he should have ordered blood tests that could have ruled out a bacterial infection.

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He also stated he should have considered both bacterial and viral infections when treating and ultimately diagnosing the toddler.

Instead, Dr Tajvidi had discharged Troy after four hours with what he thought was a viral infection.

After deteriorating, the toddler was rushed to Shoalhaven hospital the following day in cardiac arrest and was pronounced dead at 12.50pm on March 22.

In addressing Troy’s parents Kim Macklin and Daniel Almond, Dr Tajvidi said the last time he saw the child was in a corridor of the ED as he was leaving the hospital with his mother.

“I have a picture of a smiley little boy looking at me,” he said.

“Kim was one of my very respected colleagues, she is a nurse I worked with, I felt comfortable with.

“When I found out Troy had deteriorated and died the next day I couldn’t read the report.

“I couldn’t control my emotions.

“I made a mistake I accept that and I’m sorry.”

He said he knew how painful it was for him as a doctor but that was nothing compared losing a child as a parent.

The toddler’s family broke down as Dr Tajvidi made his apology.

The court heard the doctor first assessed the youngster at 11am, nurses having noted he had vomited, had a high temperature, was pale and lethargic.

Despite regular observations showing his temperature and heart rate continued to rise and a rash was found on his torso, blood tests were never conducted and he was discharged just after 2.30pm.

The inquest heard from Dr Tajvidi and registered nurses Pamela Mason and Shaun Avis that NSW Health Between the Flag procedures for sepsis pathway for recording observations in pediatric patients which raises a “red flag” for a number of health issues, such as heart rate, oxygen levels and temperature which fall outside desired levels, were not used in the ED, either in the triage area or on the pediatric ED ward.

That was despite it being mandatory and a policy of the Health Department at the time.

Dr Tajvidi said Troy’s death had led to him changing the way he treats pediatric patients and on reflection agreed in this case he could have and should have done things differently.

Ms Macklin was due to give evidence to the inquest on Tuesday afternoon but after the lunch resumption it was announced she would not be taking the stand.

Earlier in the day her statement had been submitted to evidence.

The inquest now moves to the Glebe Coroner’s Court on Thursday and Friday where deputy state coroner Teresa O’Sullivan will hear submissions heard from Shoalhaven Hospital and possibly the toddler’s family.

Ms O’Sullivan will release her findings in Nowra at a later date.