00:00My husband and I have decided to speak out now because we've finally had time to process
00:09Jo's death.
00:10We have received all the information at hand, including that critical incident investigation
00:20that was conducted.
00:22And we last week sat down with the Northern Beaches Hospital and had an open disclosure
00:29meeting.
00:31Following that meeting, we walked out and said, I think it's time to raise awareness
00:37about Jo, the systemic failings that are happening at the Northern Beaches Emergency Department
00:45that completely let Jo down.
00:47So that we can create meaningful change and ensure that no other child, no other family
00:55on the Northern Beaches has to go through what we went through.
00:59So as tough as it is, take us back through what happened on the morning of September
01:0414.
01:07So on the morning of September 14, we called triple zero.
01:14We knew that Jo was declining rapidly.
01:17He had had one vomit overnight, nothing since though, just the one.
01:22And I could actually hear his heart rate pounding.
01:25I could feel that he was clammy to touch, that he was white as a ghost, that he was
01:30floppy.
01:31He was going in and out of consciousness, even at that very early stage of 6am when
01:38we called the ambulance.
01:40They told us to make your way to the nearest emergency department, which is the Northern
01:44Beaches Hospital for us.
01:47I got there myself with Jo, Danny was minding our two other children at home.
01:54And the moment that I walked through those doors with Jo, there was no chance for survival
02:01because every plea, every call for help that I made to staff was ignored.
02:11The first mistake of many that happened was when Jo was categorised incorrectly at the
02:19point of triage.
02:21He should have been in the category two red zone.
02:25His heart rate was well into that zone at 7am at 163 beats per minute and he was wrongly
02:38triaged.
02:39A category two zone for your listeners means that it's an imminently life threatening condition.
02:47He should be seen to by senior paediatric staff within 10 minutes and his vital signs
02:53reviewed every 15 minutes, obviously put into a resuscitation bed or a paediatric bed and
02:59monitored and connected to monitoring equipment.
03:04None of that happened.
03:06The most disappointing part for us is that after our open disclosure meeting last week,
03:13we found out that indeed once he entered into that emergency department, got past that point
03:19of triage, that the staff knew he was actually in the red zone, but they chose not to follow
03:26the process and the protocol around that.
03:29Was there any explanation as to why?
03:33Yes, I asked that very question and I was told it comes down to individual performance,
03:40which simply is not good enough.
03:42That goes back to a senior layer of accountability and the question as to why they are having
03:49a long-standing staff member that inadequately cared for Jo and in addition to that, an ED
03:59advanced trainee doctor who was on rotation from St Vincent's Hospital.
04:05It's not just that, there was a senior doctor that started her shift at 8am and she never
04:11saw Jo up until the point of his cardiac arrest at 10.47am, which resulted in irreversible
04:20brain damage.
04:22He was on that table, they were trying to get a heartbeat for 29 minutes.
04:28Now as a parent, I can't tell you how harrowing that is when you feel like your child was
04:34completely let down by a system that's meant to support him.
04:38And how frustrating for you was it over those three hours from 7am to 10am?
04:47I felt that every call, every plea for help was like a door shutting in my face.
04:55There was no chance of Jo to be here today because I was told to sit back down in my
05:03chair with Jo cradled in my arms as he's agitated, going in and out of consciousness, getting
05:09worse every minute.
05:11I pleaded with him, please can he just be put on a drip, he looks very unwell.
05:16And I was told no, that is not part of their process.
05:20And to sit back down, I asked for a bed.
05:23I was told no, there's a protocol with beds, we give them to those that need them.
05:28I asked for a review of Jo repeatedly, I was pacing around the emergency department being
05:35ignored by staff.
05:39That's simply not good enough.
05:40For a state of the art hospital, built in 2018, category 5, that has a paediatric ward
05:50and they claim that they can care for children and babies adequately, I beg to differ because
05:57Jo's not here today.
05:59Not due to one failure, but due to multiple failures of processes, policies and individuals.
06:07And so an investigation has conceded those mistakes were made and the recommendations
06:13have been accepted.
06:15Is that enough?
06:17No.
06:18It's a step in the right direction and I welcome them.
06:22However, a few minor policy tweaks, a review of policies is not good enough.
06:28I want to see words that mean action, implementation.
06:33I want to see that Jo has not died in vain and a bit of paperwork is shuffled around
06:42at the hospital and a box ticked.
06:45Because when I met with the management at Northern Beaches Hospital, to me, it felt
06:51like he was just a number on a piece of paper.
06:55I had to bring a photo in of Jo and introduce him to him, humanise him, a beautiful boy
07:01that loved flowers, that loved running around in his garden and was adored by his brothers
07:06and sisters and who should be here today.
07:09I had to humanise him and take him off a spreadsheet for them.
07:14I not only want and am advocating for more to be done, that includes an independent review
07:25of the emergency department at Northern Beaches Hospital into the malpractice so that no more
07:31children needlessly have to lose their lives there, a full review of its operations.
07:37I'm also asking the state government to put funding into backing an awareness campaign
07:43for the REACH protocol so that it is in every parent's psyche that they know if they ever
07:50have to go to hospital and they feel helpless and unsafe as I did, that they know how to
07:55enact change, they are empowered.
07:59I want a text message to be sent to every single person that walks through an emergency
08:03department in any hospital in New South Wales to be sent the contact details of who they
08:09can call in the hospital if they are feeling unsafe and they wish to escalate their situation.
08:16And on top of that, I'm asking for a review into the public-private partnership that the
08:22Northern Beaches has and the government has with HealthScope because it's very clear that
08:28they're putting profit over the safety of our community.
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