An eight-year-old boy living under a government care order died from chronic asthma in a Tasmanian hospital when staff wrongly believed he was having a panic attack.
A coroner has ruled attempts to resuscitate the boy in his final moments were of a poor standard and his entirely avoidable death was due to substandard treatment.
The boy, known only as HB, was visiting his grandparents in the coastal town of Ulverstone when he was rushed to the North West Regional Hospital on June 28, 2019 "struggling to breathe".
He died five days later in hospital after collapsing in a toilet.
"He told those treating him at the hospital that he had asthma but they thought it was a panic attack. It was not," coroner Simon Cooper wrote in findings published on Monday.
"He should have been transferred to a hospital either in Hobart or Melbourne where he could be ventilated.
"Instead, he was kept at the (hospital) where he was inadequately treated, wrongly diagnosed, and died."
The boy, who had autism and lived with his other grandparents in Bendigo in Victoria, arrived in the emergency department "markedly short of breath" and was given Ventolin and antibiotics.
The paediatric team on July 1 concluded he had asthma "untreated to date" but if he continued to do well he could be discharged later that day.
In the early hours of July 3, nursing notes say he was panicking that he could not breathe and the consensus of the night staff was that it "looked more like a panic attack".
Later that morning he was "very distressed and anxious" and collapsed with respiratory arrest.
An autopsy found HB's lungs showed widespread, severe changes diagnostic of asthma and his death was acute exacerbation of chronic asthma.
Mr Cooper said the paediatric team underestimated the severity of his asthma and the night staff appeared to not have understood the "critical significance" of the fact he was no longer wheezing.
"Their assessment that he was suffering a panic attack was wrong and not supported by any objective signs or symptoms," Mr Cooper wrote.
About eight hours before his death, HB's chest was described as clear, something a doctor who reviewed the case said represented the medical emergency of respiratory failure.
"The clear chest (that is no wheeze) indicates there is insufficient air movement to generate a wheeze [and] the patient is dying," Dr Anthony Bell wrote.
"(HB) absolutely at this time required ICU treatment and major interventions."
Mr Cooper raised issues with efforts to resuscitate HB, noting evidence suggested post-intubation ventilation was too rapid and there was no record of ventilation rates.
"HB's death was entirely avoidable. It occurred because of substandard medical treatment," Mr Cooper said.
At the time of his death, HB was the subject of a child protection order in Victoria.
He was given treatment for asthma in 2015 but no formal diagnosis was made and there were no records of the prescription being followed up.
Mr Cooper noted HB's grandmother, who called the ambulance and had given him cough medicine and an inhaler in the days prior, "cared entirely appropriately for her grandson".
The Tasmanian Health Service has adopted several recommendations contained in an internal review including stricter compliance with the clinical early warning system and the inclusion of clear thresholds for escalating patient care.
The THS has also developed or updated policies regarding the administration and documentation of oxygen therapy.
"The Tasmanian Health Service apologises for the tragic death of an eight-year-old at the North West Regional Hospital," chief medical officer Tony Lawler said.
"Since that time, our focus has been on learning from what has occurred and implementing changes to ensure that such an event does not happen again."