A six-month-old baby boy who died in hospital from a lack of oxygen to the brain died because doctors failed to detect what was wrong with him and act on it in a timely manner, a NSW coroner has found.
Kyran Day was diagnosed with gastroenteritis at Nowra's Shoalhaven Hospital on October 19, 2013, but died three days later in Sydney Children's Hospital, with the cause of death listed as hypoxic ischaemic encephalopathy, NSW Deputy State Coroner Teresa O'Sullivan found on Wednesday.
The baby boy had a bowel obstruction, which was not picked up, and died despite emergency surgery.
"I offer the family my heartfelt condolences," Ms O'Sullivan told Kyran's parents Naomi and Grant Day, who had attended every day of the inquest.
Kyran's parents have known each other since they were 13. Both their mums were nurses at Shoalhaven Hospital and remain close friends.
Outside the inquest, Kyran's parents said they hoped NSW health services would improve and no other family would have to suffer like they had.
"Kyran was a beautiful baby. He was the spitting image of his dad. Always smiling, always happy. Had just gotten two bottom teeth," Mrs Day said.
"As you can imagine, having him there one day and then three days later he's brain dead is every parents' worst nightmare."
His father said the most important thing was for Kyran's legacy to live on.
"This little six-month-old boy has just impacted so many people and we're so proud of him," he said, becoming emotional.
Kyran was first taken to hospital when he awoke, pale and lethargic, early in the morning of Saturday, October 19, 2013.
He had been vomiting and was treated by several registered nurses before being seen by a doctor.
That night, paediatrician Dr Toby Greenacre examined Kyran in the hospital emergency department.
He diagnosed Kyran with gastroenteritis based on the fact he had no pain or discomfort, wasn't biliously vomiting and appeared to be sufficiently hydrated.
The next day, after being approached by Kyran's grandmother, Dr Greenacre went to see the boy and noticed "his condition had clearly changed at some point," Ms O'Sullivan said.
Following further examinations, Dr Greenacre decided Kyran needed to be transferred to a bigger hospital with better equipment and requested an airlift, but a helicopter wasn't available.
An urgent ambulance transfer was arranged but it did not arrive for more than three hours.
Following the inquest, Ms O'Sullivan made several recommendations.
These included a clearer escalation process, a root cause analysis review by Shoalhaven Hospital, implementing improved dispatch protocols, reviewing and clarifying roles and titles for the many categories of paramedics and an investigation by the Health Care Complaints Commission into the conduct of some health practitioners.
She also gave the NSW Ambulance Service and NSW Health Department timeframes for several recommendations and said they would need to explain if they had not been done.
"Children and babies don't have a voice. Kyran couldn't say to me "mum, something's seriously wrong." I had to be the voice for him," Mrs Day said.
"I want all parents and grandparents and everyone to be able to feel comfortable and say there's something wrong. The escalation process will help."
Strategies are being developed to ensure concerned loved ones are listened to if a hospital patient's condition deteriorates, NSW Health Minister Jillian Skinner says.
"Kyran's name and photograph will be included on information posters and brochures which will be available to families of all paediatric patients on admission to hospital," Ms Skinner said after the findings were released.
"Kyran's mother will also tell his story in a training video for NSW Health staff."