Triage nurses 'don't have time' to check on patients, inquest told

The coronial inquest into the death of Rozalia Spadafora continued on Monday, December 4. The little girl died at Canberra Hospital on July 5, 2022, after waiting in the emergency department for five hours.

In 2021-22, Canberra Hospital waiting times were more than double the national average, and the ACT has longer waiting times than any other state or territory.

In what appears to be another communication mishap between staff, Rozalia's triage nurse Manda De Amos said she had not been told the child's condition had deteriorated a few hours after admission.

Ms De Amos said if she had known, she had the power to escalate Rozalia's care by placing her into a higher category or taking her straight to a doctor.

About 7pm on July 4, Ms De Amos placed Rozalia into category three, meaning she should have been seen by a doctor in 30 minutes. There are five levels of triage, and category three is "potentially life threatening".

In her notes, Ms De Amos noted that Rozalia was lethargic and had a swollen eye. She said it was not usual to take the blood pressure of children at triage.

"Sometimes the child is agitated [so] it will not give you the proper reading," she said.

A paediatric doctor previously told the inquest that Rozalia should have had her blood pressure taken at triage, and that she may have already been in cardiac failure at that time.

There was an electronic colour-coded system to see which patients had waited longer than the recommended time in the emergency department, but Ms De Amos said triage nurses did not have time to check it.

"After you see the patients, there's another patient in front of you and you really don't have time to go back to the patient again," she said.

The nurse did not believe it was the responsibility of any other staff member to see how long patients had waited to be seen by a doctor.

She also said children did not usually have priority over adults when being triaged or while waiting.

Ms De Amos said she believes the emergency department was busy that night because four nurses had been rostered on, instead of the usual three. This would be to cover increased demand.

The doctor in charge of the emergency department that night previously told the court that the department was "extremely busy".

Observations recorded at 9.55pm by a different nurse, about three hours after she was first admitted, showed that Rozalia's condition had deteriorated. However, Ms De Amos said this had not been brought to her attention.

Ms De Amos also said general practitioners could send clinical notes to the department via fax or by providing a written letter. They can also call, but they will not be put in contact with the triage nurse over the phone, she said.

General practitioner Dr Khaleda Yesmin previously told the court she did not send any notes to the hospital because Rozalia would be checked by triage nurses anyway.

Nurse Samantha Sherd, who has since left Canberra Hospital, said while urgent test results "shouldn't" have been left on post-it notes, they sometimes were.

The result of an important test result, a troponin test, was left next to Rozalia's bed on a post-it note and acted on hours after it was ordered.

Ms Sherd said the pathologist may have called one of many phone lines, making it hard to identify who would have written the note.

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That includes an administration number, clinical number, navigator number or medical telephone number, Ms Sherd said.

The then-senior nurse in the emergency department also admitted she did not give Rozalia a tablet when asked to by a doctor.

She said this was because she had just come back from lunch, Rozalia was not her patient, she did not know the doctor or what the medication was, and did not see a medication order. She said she also made a clinical judgment that Rozalia would not have been able to swallow the tablet anyway.

Ms Sherd was not asked if she passed on this information to any other nurse or doctor.

The inquest is expected to continue on Monday afternoon.