A doctor who wrongly diagnosed a 19-month-old with gastro, days before he died of meningitis,says the misjudgement was a "major error".
Paul Bumford told an inquest he was working his first shift at Wangaratta Hospital, in northeast Victoria, when an unwell Noah Souvatzis arrived on December 29, 2021.
The toddler had been holidaying with his parents, Ben and Steph, in nearby Myrtleford, when he became ill, vomiting, crying for hours and had a high fever.
He was earlier brought to an urgent care centre in the town after becoming severely lethargic and unable to keep fluids down.
A nurse at the Alpine Health facility noted symptoms of lethargy and increased heart and breathing rates before advising Noah be taken to hospital.
Dr Bumford, who was employed on a locum basis at hospitals across the state, clocked in about an hour after Noah was admitted to the emergency department.
The toddler was discharged by Dr Bumford three hours after his admission, before he was brought back to the hospital by his parents hours later.
Noah was eventually flown to the Royal Children's Hospital in Melbourne after further deteriorating and diagnosed with bacterial meningitis.
At 3.11pm on December 30, Noah was declared brain dead.
Dr Bumford "wholeheartedly accepted" meningitis and sepsis "should have been on my list, that was a huge error on my part".
He also said not correctly picking up the symptoms was "in hindsight is terrible from me but that's my honest answer".
"Obviously there have been a lot of failings on my part," he said.
"I put far too much weight on these observations when I should have looked at the bigger picture."
Dr Bumford said Noah's treatment and misdiagnosis constantly played on his mind.
"I've thought about (what I could have done differently) probably every day since it's happened," he said.
"A big problem for (the parents) was me not listening to them.
"I've thought about that a lot."
Dr Bumford said he received no onboarding from the hospital on the day of his first shift except for providing immunisation history.
"Obviously everyone looked very busy. I had difficulty finding someone to direct me into the actual department," he said.
"It seemed fairly chaotic and busy to me, but I didn't really have any reference point (for what the hospital was usually like)."
Earlier, a nurse who treated Noah broke down in tears when she recalled him being "pale, hot and flat" when being admitted.
"I do still remember that day," Read Moreland said.
The next morning, Ms Moreland messaged the nurse in charge to say she was surprised Noah was discharged without a pediatric referral, the inquest heard.
She said the hospital and its staff had been under immense pressure at the time due to the pandemic.
Outside the Coroner's Court on Monday, Noah's parents remembered their son as a beautiful, gentle boy who loved cuddles.
"We want to prevent what happened to Noah from happening to other Australian kids," Mr Souvatzis told reporters.
"We know our little boy would still be here today if all the medical services provided the expected level of care.
"Parents shouldn't have to scream to have their concerns heard and their children cared for."
A Northeast Health Wangaratta representative on Monday conceded the care provided to Noah was not appropriate during his first presentation and apologised to his family.
