Rozalia Spadafora arrived at the Canberra Hospital emergency department limp and pale in her mother's arms on her fifth birthday, July 4, 2022.
She died within 28 hours.
A series of "missed opportunities", poor communication and disturbing mistakes left a family devastated, hospital reeling and government scared.
Over nine days in October and December of this year, the Spadafora family piled into a courtroom to rake through the worst day of their life, over and over again.
One-by-one, seemingly nervous nurses and doctors turned up to the witness box in front of tables of lawyers, who had swelled in numbers by the second week of the coronial inquest.
Witnesses apologised and cried through questioning. One ran from the room in tears. Many seemed terrified they would be blamed for Rozalia's death.
A health official said the ACT has struggled to care for critically ill children for many years.
The inquest ended with three experts who explained what they think went wrong and what needs to change.
As coroner Ken Archer remarked, the inquest was a "fairly confronting sort of experience".
"It has been for everybody in the room," he said.
Because what seemed to unfold was not one fatal mistake but a succession of "missed opportunities" and errors.
The GP visit: Monday 5.30pm
Rozalia had been sick for two days, the family said. At her birthday party the day before, the usual "bubbly spark of light" spent all her time on the couch.
Katrina Spadafora had taken her daughter to an after-hours medical service at Canberra Hospital on Sunday night. She was prescribed a steroid and antihistamine for puffiness.
They did not think the medication had worked, so saw general practitioner Dr Khaleda Yesmin at 5.30pm on Monday.
"Her heart is racing," the GP said. She told Ms Spadafora to take Rozalia to the emergency department, but did not give her clinical notes.
Five hour wait: Monday 7.30pm
Rozalia, Ms Spadafora and grandmother Maria Callipari arrived at the emergency department at 7.30pm. While Rozalia was usually a "pocket rocket", Ms Spadafora said she had to carry her while lining up for about half an hour.
The nurse who triaged Rozalia put her as category three, meaning she should have been admitted within 30 minutes. During this period, less than a third of these patients were seen on time at Canberra Hospital.
The nurse did not take her blood pressure, which the experts agreed was normal.
The family said that an hour after triage, another nurse suggested they take Rozalia home and see a GP in the morning. The little girl was laying on their laps in armchairs, pale, falling in and out of sleep.
They stayed.
Observations taken by an unknown nurse at 10pm showed Rozalia had gotten sicker. Experts said because Rozalia's vital signs had deteriorated, her blood pressure should have been taken. It wasn't. If it had been, Rozalia may have been seen sooner.
First medical review: Tuesday midnight
The child first saw an emergency department doctor at midnight.
It was reasonable for Dr Tze Hao Wong to think Rozalia was dehydrated and had a virus, experts told the court. Her blood pressure still wasn't taken.
Dr Wong wrote that Rozalia was flat, pale and disengaged. He was concerned she had cancer. Ms Spadafora said she was asked to give Rozalia electrolytes, which the little girl threw up.
Another doctor said that later that night, Dr Wong called Rozalia the "sickest child he'd looked after" and shuddered at her name.
Second medical review: Tuesday 4am
Paediatric registrar Dr Callum Jarvis reviewed Rozalia at 4am. He was the first person to take her blood pressure and conducted a thorough assessment, according to experts.
But they said that at this point, clinicians could have been considering an alternative diagnosis to dehydration.
Bed review: Tuesday 5am
Following further blood tests at about 5am, Dr Jarvis said he asked intensive care doctors to review Rozalia.
She was given a large amount of fluid, which the inquest heard may have made her heart issues worse.
What exactly was asked and discussed between the ICU and paediatric teams is contentious.
But the court was told intensive care doctors did not review Rozalia. A senior ICU doctor told the inquest his colleagues could not physically examine her without a parent or guardian present.
Heart scan: Tuesday 7am
The experts said that by about 7 to 8am, doctors had enough information to diagnose Rozalia with myocarditis - the heart condition she likely died from.
This included an echocardiogram, or heart scan, which showed evidence of heart inflammation, and a test result which was inconsistent with the theory Rozalia was dehydrated.
Dr Jarvis and paediatric consultant Dr Anne Mitchell said they could not see anything notable on the ECG results. The experts disagreed, and said signs on that heart scan were "not subtle".
The experts also noted Rozalia had an enlarged liver, which was likely due to the right side of her heart failing.
Handovers: Tuesday 8am
What happened during the handovers between night and day medical teams is disputed, but the court was told that little information about Rozalia was effectively passed on.
No one in the ED thought they were responsible for the little girl because a rostering sheet had conflicting information. The inquest heard the day paediatricians did not speak to the emergency doctors.
An important test result ordered by an ED doctor was not assigned for anyone to chase up, the court heard. This test would ultimately confirm Rozalia had a serious heart problem.
Paediatric registrar Dr Jade Stewart said when she raised the idea Rozalia might have a cardiac issue during handover, she was dismissed. The paediatric team said they were not aware the critical test had been ordered.
Critical test result: Tuesday 10.30am
One of the most contentious issues in the inquest was who knew about a critical pathology result and when.
Nurse Sarah Retford said she found the test result on a post-it note at the foot of Rozalia's bed.
Around this time, an intensive care doctor said he decided there was no need for the department to be involved in Rozalia's care because she was being moved.
Dr Stewart said she knew about the result at 11.30am but did not tell Rozalia's paediatrician, Dr Mitchell, until 30 to 45 minutes later.
Diagnosis: Tuesday 12.30pm
Rozalia was finally diagnosed correctly at midday. Doctors said they could tell she was extremely sick.
They said they considered giving her medication to support her heart, and called specialist doctors from Sydney for advice.
Senior intensive care specialist Dr Simon Robertson believed Rozalia would not accept an oxygen mask, but experts said doctors should still try in such cases.
Communication with the Sydney specialists seemed limited, experts told the inquest.
Lines: Tuesday 4pm
Rozalia was finally moved to the ICU.
Dr Robertson said it took him about 45 minutes to put a line into one of Rozalia's main arteries while she lay awake, a process he called "inhumane", "confronting" and "disturbing", but necessary.
Observations showed Rozalia was becoming breathless, her heart rate was faster and her pulse was harder to detect. She was in shock, experts said.
One expert told the court doctors failed to do a number of tests which would have showed them how critically ill she was.
NETS arrives: Tuesday 7pm
At 7.15pm, Rozalia was described as "grey and unwell".
The neonatal emergency transport service arrived in Canberra around this time.
However, Rozalia was not considered stable enough to go to Sydney without intubation.
About half of children with Rozalia's form of myocarditis die, and being transferred would not have guaranteed her survival.
Final hour: Tuesday 9.30pm
At about 9.40pm, "Rozalia made some gasping movements and stopped moving in the bed. That's the point at which her heart rate started to move down", Dr Robertson said.
Medical staff spent 68 minutes trying to resuscitate Rozalia, but she was declared dead at 10.50pm.
Ms Spadafora and her mother were rushed out of the room. Ms Spadafora was asked by the court what her daughter's last words were.
"She just called my name," Ms Spadafora said, her voice cracking.
The coroner's report is expected to be handed down in 2024.
