Inquest Into The Death Of Rozalia Spadafora

5y · Female·myocarditis

A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Category 3 assignment but no medical review for 5 hours (required within 30 minutes); misinterpretation of an abnormal ECG by both the registrar and consultant paediatrician; lack of allocated responsibility for following up troponin test results; failure of ICU to properly assess the critically ill child despite consultation; inadequate handover processes with siloed information across departments; and excessive fluid administration straining the failing heart. By 0740 hours sufficient clinical evidence existed for myocarditis diagnosis (abnormal ECG, influenza A, hypotension, tachycardia, hepatomegaly). Earlier recognition and appropriate management including fluid restriction and timely NETS transfer might have provided a chance of survival with ECMO support in Sydney.