00:00It was meant to be a day of celebration, but Rosalia Spadafora's fifth birthday would be her last.
00:09The girl, described as a bubbly spark of light, woke up lethargic, without her usual appetite.
00:15After multiple GP visits, her family was left with nowhere else to go but the emergency department.
00:22Rosalia arrived at the hospital at 7pm on the 4th of July.
00:27She was triaged at 7.40 and should have been seen by a doctor within half an hour.
00:32But that didn't happen until after midnight.
00:35Rosalia had an ECG shortly before 7am. The result was misread.
00:41A test result indicating damage to the heart lining was available shortly before 10am,
00:47but wasn't made clear to the treating doctor until after midday.
00:52By the time staff were preparing to transfer Rosalia to Sydney, more than 24 hours after she'd first presented,
00:59she was too unstable for the journey.
01:02The coroner described those delays as unreasonable.
01:06I find that the delay in Rosalia's diagnosis and the failure to provide Rosalia with appropriate treatment
01:12in a timely manner meant that any opportunity Rosalia may have had for survival was lost.
01:18Rosalia's family filled the courtroom today, her mother still wondering what more she could have done.
01:25Over two days, nine consultations with health practitioners, my mother and I tried to get my daughter the help she needed.
01:33We failed at every step and watched her slowly die in front of us.
01:37We're confident with the changes that we've introduced over the last couple of years
01:43and the gains that we've already seen that we've made, this would not happen under the same circumstances today.
01:49But Mr Pfeffer wouldn't be drawn on whether anyone would lose their job.
01:54Ultimately, I'm the leader of the health service and this is my accountability.
01:59The health minister said she would also write to the family expressing her and the ACT government's condolences.
02:06Canberrans are entitled to expect the very best care at Canberra Health Services, she said.
02:11I acknowledge that the care provided to Rosalia tragically did not meet those standards.
02:17My family cannot have any confidence in CHS or this government to safely look after our children.
02:22The findings came on the same day as the release of updated data on emergency department wait times,
02:28which appear to show some improvement in the ACT.
02:32The coroner said Rosalia's death served as a reminder of the potential consequences of delays in the ED.
02:39I'm here so no other mother will suffer my unrelenting grief and guilt.
02:44Grief that will undoubtedly remain forever.
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