Deputy state coroner Teresa O’Sullivan will release her findings into the death of 17-month-old Nowra baby Troy Almond on Monday, December 3.
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The baby died In March 2016, less than 24 hours after being discharged from Shoalhaven District Hospital’s emergency department.
The coronial inquest into Troy’s death started in Nowra on November 19 before moving to the Glebe Coroner’s Court last Thursday.
A panel of expert witnesses, including Professor Anne-Maree Kelly, Professor John Raftos and Dr Michael Golding, gave evidence on Thursday.
On Friday, Troy’s parents Daniel Almond and Kim Macklin read victim impact statements.
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The inquest heard the toddler had a temperature and was lethargic and vomiting when his mother took him into Shoalhaven Hospital ED just after 10am on March 21, 2016.
After spending fours hours in the ED he was discharged, suffering from what was described as a viral infection.
However, Troy's condition deteriorated overnight and he woke the following day with diarrhoea and had begun vomiting again and became “unresponsive" later that morning, prompting his parents to phone triple zero.
They performed CPR until paramedics arrived and transported Troy to hospital, where he was pronounced dead at 12.50pm.
An autopsy revealed Troy had died from sepsis.
As ED doctor Babak Tajvidi, who treated Troy, concluded his evidence before the inquiry in Nowra, he apologised to the boy’s parents saying he was “sorry” and had “made a mistake”.
During his evidence he conceded the toddler “most likely” already had sepsis, which ultimately killed the child, when he first presented to hospital.
Dr Tajvidi said in hindsight he should have ordered blood tests that could have ruled out a bacterial infection.
The inquest heard from Dr Tajvidi and registered nurses Pamela Mason and Shaun Avis that NSW Health Between the Flag procedures for sepsis pathway 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.
