Troy Almond was just 17 months old when he died on March 22, 2016, less than 24 hours after being discharged from Shoalhaven District Hospital emergency department.

An autopsy revealed he had died of sepsis - septicaemia due to Streptococcal (Beta Haemolytic Group A) infection.

Ms O’Sullivan found the toddler died due to the failure of treating specialist at Shoalhaven District Hospital to recognise signs of toxicity caused by possible sepsis, to investigate the possibility of sepsis, and to administer antibiotics.

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She accepted expert opinions the bacterial infection was treatable with early detection and early administration of antibiotic therapy to which the microorganism was sensitive.

Troy’s parents Kim Macklin and Daniel Almond sat in the court holding hands, a portrait of their late son on their knees.

At times they were physically upset as the coroner delivered her findings.

Ms O’Sullivan said expert testimony showed a full blood count for Troy, which wasn’t carried out, could have shown an increased white blood cell count, predominantly neutrophils (a sub set of white blood cells which kill bacteria).

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 where he received treatment from triage registered nurse Pamela Mason, pediatric registered nurse Shaun Avis and emergency department staff specialist Dr Babak Tajvidi, he was discharged suffering from what was described as a viral infection.

The inquest heard a number of NSW Health Between the Flag  [BTF] 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.

A Standard Paediatric Observation Chart (SPOC) for infants aged one to four years was supposed to be used but was not used in paper form at all for monitoring patients in the ED.

The observations were recorded in an electronic form (IView - computer system) but not directly into a colour coded chart that depicted the BTF approach.

Troy had red and yellow flags with an high temperatures and increased heart rates.

The toddler’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.

Doctor Tajvidi concluded his evidence to the inquest by apologising to Troy’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.

Ms O’Sullivan stopped short of recommending a request by counsel for the Almond family that “SDH consider implementing an orientation program for all new staff commencing work within the emergency department that identifies all between the flags and sepsis guidelines that are utilised within the ED which involves a demonstration of the documents and/or computer software used within the ED to implement those guidelines”.

She said procedural changes had already taken place at Shoalhaven Hospital, including ongoing training regarding the guidelines.

However, she encouraged the hospital to “continue to review and update their staff orientation and training with respect to BTF and sepsis policies as appropriate”.

Ms O’Sullivan expressed her gratitude to Troy’s parents, Kim and Daniel, who attended every day of the inquest.

“Their dignity and patience throughout the coronial process was admirable. I know that there are no words to comfort them. The best that I can do is to acknowledge the enormity of their loss and their love for their beautiful son, Troy,” she said.