A Sydney nurse has made an admission about the death of a two-year-old boy two years ago.
Triage nurse Hilary O’Neill apologised to Joe Massa ’s parents on Tuesday during the second day of a coronial inquest into his death.
“I am so sorry. I am human, and I think about Joseph every day. I feel terrible that I missed his heart rate … I think I played a role, and the system let you down,” she said.
Joe was brought by his parents, Elouise and Danny Massa, to the emergency department at Northern Beaches Hospital on the morning of September 14, 2024, after vomiting and dry retching at their Balgowlah home the night before.
O’Neill recorded Joe’s heart rate at 182 beats per minute, well above the normal range for a two-year-old of between 70 and 110bpm.
Despite the reading falling within the hospital’s “red zone”, Joe was triaged as a category three patient.
O’Neill told the inquest that had she recognised the significance of his elevated heart rate, she would have classified Joe as a category two patient, requiring more urgent treatment.
That classification would have seen Joe taken to a bed and placed under continuous cardiac monitoring.
“There were no track or trigger systems in place to alert me that it was in the red zone,” she said.
O’Neill also told the inquest she was nearing the end of a 12-hour overnight shift with little opportunity for a break and had been assaulted by a mental health patient during the shift.
“This is a career I love, and I’m now terrified of it. I hope you get some closure and the answers you need,” she said.
A second nurse, Elaine Stork, later recorded Joe’s heart rate at 197bpm but said the hospital’s emergency notification system also failed to alert her when she entered the reading.
Stork said she could have been more proactive, telling the inquest she had attributed his elevated heart rate partly to dehydration and his movement at the time.
“I just attributed a bit of that to the dehydration and the fact he was squirming,” she said.
“I’m sorry for what you guys have been through. I do wish I had taken more observations,” she said.
“I have reflected … I’m extra vigilant in my practice, and I’m happy about some of the changes that have come from this.”
Elouise said at the time her instincts as a mother had told her that her son needed more urgent medical attention.
“I don’t have any medical training, but I do know my son and I did know that he was deteriorating. He was not getting any better. He was getting worse by the minute. And I could see that visually,” Elouise said.
The couple allege that “his entire time at the Northern Beaches Hospital, there was no urgency shown”.
Joe was eventually transferred to Sydney Children’s Hospital, where he died two days later after his parents made the decision to withdraw life support.
Northern Beaches Hospital has since returned to public ownership.