Two Canberra Hospital emergency doctors claim the other was responsible for treating a sick child who ultimately died.
On Monday, emergency department staff specialist Dr Amy Ying Yee Ting gave evidence at an inquest into the death of five-year-old Rozalia Spadafora.
Rozalia died on July 5, 2022, of cardiac failure, after developing heart condition myocarditis from an influenza A infection.
The inquest has exposed what appears to be a series of miscommunications - or "missed opportunities" - in the 28 hours between Rozalia turning up to the ED and dying.
Bed allocation confusion
In the first half of 2022, the roster determining which consultants - senior doctors - were responsible for which beds in the emergency department changed multiple times, Dr Ting told the court.
She said they eventually decided on a map, which divided the emergency department into three wings - north, south and west - and allocated beds to each section.
Senior doctors would be assigned a section in advance. A day roster sheet would be printed out and any amendments handwritten on the sheet on the day.
On July 5, Dr Ting was assigned the southside section, and Dr Kirsty Dunn the northside section.
On the day sheet, Dr Ting acknowledges the terms R1 and R2 were handwritten next to the northside section.
These refer to resuscitation (resus) beds one and two. Rozalia was in resuscitation bed two.
Dr Ting acknowledges she had seen the sheet before starting work that morning, and had made a note that a junior doctor had called in sick, but said the consultants were sticking by the default map.
"I don't know why that's there, but the true allocation is based on what's written on the bottom of the page," she said.
"It is a common understanding with consultants of how the emergency department has been laid out."
Dr Ting strongly rejected a suggestion from Dr Dunn's lawyer, Joshua Nott, that the handwritten notes reflected how the beds were assigned that day.
"No, that's not true," she said.
"Resus one and two [is in] the northside geographical area of the department.
"It would appear that's what is written on there, but that isn't the truth of the document."
Nurse navigator Analiese Vartianen, who worked in the emergency department on July 5, said reallocations of beds were common at the time, and could happen due to staffing levels or how sick each patient was.
She also said it could happen during a shift, but she was more likely to refer to the allocation at the bottom of the page, which Dr Ting was working off.
"That always had the ability to have changed based on the needs of medical resources," Ms Vartiainan said.
The nurse also gave evidence that Dr Dunn told her Rozalia no longer needed to be in resuscitation bay, which has three nurses to five patients, shortly after handover.
Confusion and misinformation
Dr Ting said if she had been assigned those resuscitation beds, it would have created issues around responsibility for other resuscitation beds.
There was no mention of who was allocated Rozalia during the handover from night staff to day staff, Dr Ting said.
She did not agree she should have raised the handwritten notes with other staff during handover.
Dr Ting said her usual practice was to review each patient at the beginning of her shift, observing them and looking at their notes.
Several witnesses have told the court that the paediatric team were responsible for Rozalia's care, but emergency department staff were available if she became more ill.
Dr Ting said she first became involved in Rozalia's care when paediatric registrar Dr Jade Stewart told her about a very concerning test result.
"I realised that she needed immediate care," Dr Ting said when asked why she proceeded without informing Dr Dunn, who said she was responsible for Rozalia.
In another apparent communication bungle, Dr Ting also said she was told intensive care unit (ICU) specialists had reviewed Rozalia.
The court previously heard from paediatrician Dr Callum Jarvis that ICU doctors did not review the little girl because they did not have enough experience with children.
Mysterious note
Dr Ting's evidence also illuminated further information about a mysterious slip of paper, on which was written the result of a troponin blood test.
That blood test, which revealed Rozalia was seriously ill, was left in her patient file.
Counsel assisting Michael Fordham previously told the court that the writer of the note had not been identified.
While the blood test was ordered at 7am, the results were available at 9.56am and the note was only found at around midday, two hours later.
Dr Ting said pathology may have had results even earlier than 9.56am.
She said pathology results would be updated on a computer system, which doctors would have to check themselves.
If pathology returned an urgent result, such as the positive troponin result, they would phone the ward the patient was located in.
A ward clerk would then write down the result on a slip of paper, and hand it to the doctor responsible for the patient.
Occasionally, if a doctor could not be found, it would be given to a nurse, Dr Ting said.
Dr Ting said any nurse in the resuscitation bay and all doctors would understand the importance of the troponin results.
"Most resus nurses are highly trained," she said.
"I think they would understand the significant of it [and escalate]."
