Death of Noah Souvatzi: Doctor Paul Bumford turned up for his first ever locum shift at a new hospital. Then he made a devastating decision that would change a family’s life forever

A heartbroken doctor who discharged a seriously ill toddler from hospital, leading to his death, has revealed what went wrong.

Doctor Paul Nicholas Bumford told the coroner at the inquest into the death of 19-month-old Noah Souvatzis that he believed the child had gastro when he examined him at Wangaratta Hospital on December 29, 2021.

Dr. Bumford, who was on his first ever locum shift at the regional Victorian hospital, discharged little Noah just three and a half hours later. But the toddler and his parents returned soon after as his condition dramatically worsened.

Noah was then flown to the Royal Children’s Hospital and at 3.11pm on December 30 the toddler was declared brain dead.

His life support was turned off on December 31 after the toddler’s organs were donated.

Despite vomiting during his discharge from hospital, Noah Souvatzis (pictured in hospital with his father Ben) was sent home. The toddler’s condition worsened and his parents brought him back a few hours later

Doctor Paul Nicholas Bumford (pictured leaving the inquest into the death of Noah Souvatzis on Tuesday) told the coroner in retrospect he wished he had consulted a more senior doctor

Dr. Bumford told the coroner Tuesday that, with the benefit of hindsight, he wishes he had asked a more senior doctor to evaluate Noah, The age reported.

He also said he wished he had done further checks and referred Noah to the pediatric team to keep him under observation for longer.

“Given that his condition had improved, I felt it was fair to discharge him. I am devastated by (the outcome),” Dr Bumford said.

The Coroners Court heard from other witnesses who said Wangaratta Hospital had chronic staff shortages, long ambulance waiting times, internal conflict and that its staff lacked experience and seniority.

Covid restrictions were in place in parts of Victoria at the time, which also added to the strain on the health sector.

Triage nurse Read Moreland had tears in her eyes as she told the coroner: ‘It had been pretty awful.’

“I still remember that day,” she said.

Noah Souvatzis (pictured) was declared brain dead and had his organs donated

The Souvatzis (pictured) had been on holiday in regional Victoria when 19-month-old Noah became unwell

The nurse said the days leading up to Noah’s arrival were a ‘storm’ and recalled texting others about her concerns.

‘I don’t know that we’re all going to survive…over the next few weeks/months.’

Mrs Moreland told the inquest while everything at the hospital had been controlled during the lockdowns, as soon as everything reopened, no extra resources had been given to help with the extra workload from holidaymakers.

The triage nurse also said it had become common to hear of patients who had tried to get an ambulance but were told it would be faster to drive in themselves, which is what happened in Noah’s case.

Mrs Morehead described the ambulance wait as ‘terrifying’ for the patients and ‘us sometimes’.

The toddler’s parents, Ben and Steph Souvatzis, had been holidaying in the area and previously told the coroner they were repeatedly forced to take their increasingly ill boy to various health services and were mostly turned away.

Wangaratta Hospital (pictured) was described by a triage nurse as being understaffed at the time and a ‘storm’ in the days leading up to Noah’s arrival in A&E

The family first arrived at Alpine Health Care Center in Myrtleford around 2.30pm but were sent to Wangaratta A&E where they arrived around 15.45.

They were then discharged from Wangaratta at around 7.20pm, with Ben Souvatzis telling the inquest that Noah was a sicker child than they arrived with.

Souvatzis had reminded the court that panic and disagreements among staff were rife as he nursed a semi-conscious Noah in the emergency room waiting line.