Two-year-old Joe Massa had “no chance of life” once he walked through the doors of the emergency department at Northern Beaches Hospital in Australia — even though he could have been saved with something as simple as an IV drip.
For the devastated parents of the “bright and loving” little boy, who loved dinosaurs and playing in his garden, what should have been a routine hospital visit last September turned into their worst nightmare.
Elouise and Danny Massa say their beloved Joe’s preventable death was caused by systemic failures at Northern Beaches Hospital, leading to a dereliction of duty, critical delays and misdiagnosis.
They are demanding urgent reform and accountability to ensure it doesn’t happen to another family.
“Joe had no chance of life once we walked through the doors of the ED,” Elouise told news.com.au. “That’s the whole purpose of speaking out.”
Joe was taken to the emergency department at the Frenchs Forest hospital on the morning of Sep. 14, after experiencing vomiting the previous night.
By the time they arrived at the hospital at 7.06 a.m., Joe had a dangerously elevated heart rate and was pale, floppy and growing unresponsive.
The boy was suffering significant hypovolemia, a condition that occurs when the body loses too much fluid — and that would typically be treated by IV fluid resuscitation.
Crucially, the ED triage nurse documented that Joe was in triage category three, which indicates a patient requiring treatment within 30 minutes, rather than the “red zone” category two, defined as requiring treatment within 10 minutes due to an imminently life-threatening condition.
A Serious Adverse Event Review (SAER) later confirmed Joe’s heart rate of 182 beats per minute (BPM) should have placed him squarely in category two and triggered a “rapid response”.
At 7.39 a.m., more than half an hour after arriving at hospital, a nurse collected Joe and his mother and walked them to pediatric emergency, where he was placed in a chair despite there being beds available at the time.
The SAER noted that staffing levels at the time were normal and that the ED waiting room volumes were “lower than usual”.
Once admitted, Joe was primarily under the care of an ED registered nurse and an emergency advanced trainee doctor.
His heart rate by this point had jumped to 197 BPM, but still he was not elevated to category two. He was misdiagnosed as a case of gastro, and over the next three hours hospital staff ignored critical warning signs including his skyrocketing heart rate, limpness, rash and loss of consciousness.
It wasn’t until 10.30 a.m. that another ED nurse realized Joe was gravely ill, and he was transferred to the resuscitation bay.
At 10.47 a.m., Joe suffered a catastrophic cardiac arrest. CPR was initiated for 29 minutes, but he could not be saved. The prolonged period of CPR caused severe irreversible brain damage.
According to Elouise, at no point up until his cardiac arrest was Joe even hooked up to monitoring equipment for his vital signs. Elouise said that on “at least three occasions” she asked for an IV drip.
If either of these things had been done, he would more than likely still be alive today.
“The system at Northern Beaches hospital failed us at every possible level,” she told 2GB’s Ben Fordham on Thursday.
“Joe was the most beautiful boy, loved by his sister and brother. He had the most infectious smile. He had his whole life ahead of him. We do not want one more family on the Northern Beaches to go through what we’ve had to go through.”
Danny described how he arrived at the resuscitation bay “the moment he passed away”.
“He went into cardiac arrest the moment I touched his face,” he said.
Elouise added, “Because we were being ignored, I wasn’t able to hold Joe’s hands during his last breath. He turned to his side and vomited, a tear rolled down his cheek — and I was still screaming down the phone at a friend to get him out of that hospital.”
The SAER, submitted to the NSW Health Ministry on December 20, identified a number of serious failures in Joe’s case including “failure to recognize and respond to a heart rate in the red zone particularly in the absence of fever”, “failure to respond to parental concern” and “failure to respond to clinician concern as per internal escalation processes”.
It also recommended reviewing the hospital’s patient IT systems that currently do not automatically flag and escalate dangerous vital signs.
“During the SAER investigation, it was identified that two clinicians’ professional practice was not to the expected standard and have referred this to the hospital’s executive unit for further management,” the report said.
“The SAER team acknowledge they cannot say definitively that the child’s death was preventable, however, they do acknowledge that there was a delay/failure to recognize deterioration. The SAER team accept that an earlier recognition of the deteriorating child may have provided an opportunity for early escalation and resuscitation with potential prevention of the cardiac arrest event.”
According to the parents, both the ED registered nurse and the emergency advanced trainee doctor are believed to still be working in the NSW health system.
“The ED registered nurse who had been at the hospital for six years failed,” Elouise told news.com.au.
“She didn’t follow protocol. The ED advanced trainee doctor he barely reviewed Joe, he took no care of his vital signs. But I don’t want to say it all comes down to those two. The senior consultant emergency doctor started at 8am that morning and never once saw Joe — where was she?”
The family have called for an independent public review into “serious malpractice and operations at NBH emergency department”, as well as “statewide enforcement of the REACH protocol informing every parent or carer upon admission of their right to escalate concerns when their child is deteriorating, including a text message notification” and “urgent IT system upgrades” to ensure immediate alerts for at-risk patients when human error occurs.
They also want greater scrutiny on the Northern Beaches Hospital’s public-private partnership (PPP) model, operated by Healthscope since October 2018, which they suggest prioritizes financial interests over patient wellbeing.
Northern Beaches Hospital’s controversial privatized model was announced by the former Liberal government in 2015.
It’s the only one of its kind in the state after strong public opposition led the former government to scrap plans to expand the model to Maitland, Wyong, Goulburn, Shellharbour and Bowral.
“Northern Beaches Hospital offers its deepest condolences to the Massa family for the loss of their son, Joe,” a spokesman said.
“We recognize Joe’s death has caused unimaginable heartache and grief for the family. We have met with the family to apologize and hear directly about their tragic experience and to discuss the findings of the Serious Adverse Event Review.
“We will continue to support the family in any way that we can as we implement the improvements identified in the review, including improvements around triaging processes and internal escalation processes.”
New South Wales Health Minister Ryan Park is due to meet with the Massa family next week.
“My heart goes out to Elouise and Danny — this is a terrible tragedy,” Park said in a statement.
“As the Minister for Health, this is among the worst possible things that can happen in our health system — a young child who should be with us is no longer alive. I have had the opportunity to speak with the parents directly — I never want any parent to go through this.”
Park said in the last 24 hours he had discussed the incident with the Secretary of NSW Health “to understand actions being taken in response to this tragedy”.
“A Serious Adverse Event Review has been undertaken and I can confirm Northern Beaches Hospital have accepted all recommendations,” he said.
“I have made it clear to NSW Health all recommendations need to be implemented in full and as quickly as possible. This incident raises serious questions about privatization and this type of model — the matter of which is the subject of an Auditor General’s review.”
