Nobody to blame

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Frustrated and upset, the Costa family’s search for closure remains unsettled following the unexpected death of their daughter Chanel, 4, in 2008.


The findings of a coronial inquiry into the circumstances of her death, held at Glebe Coroner’s Court this week, have given the family little understanding as many questions surrounding the treatment and state of NSW’s health system remain unanswered.

“We expected so much more… the coroner, Carmel Forbes, had the power to change the NSW health system but she didn’t. The health system failed us and now the legal system has too,” explained dismayed father, Steve Costa.

Three medical specialists asked to review the case suggested that Chanel may have had Reye’s syndrome, which has no known cause but commonly occurs in five to 14-year-olds with symptoms of rapid deterioration of the liver and brain.

In her findings presented to the court on Monday, Ms Forbes said: “Chanel’s death has been treated very seriously… in all the circumstances, I am of the view the management of Chanel’s condition could not be criticised or said to have caused her rapid cerebral oedema [swelling on the brain]”.

But recounting the dreadful days of July 2008, Mr Costa said he did not understand how the coroner could find no fault with the treatment given to Chanel.

In the early hours of July 15, 2008, concerned parents, Steve and Angela, took their daughter to the emergency ward of Nepean Hospital seeking treatment for symptoms she developed during the night – a high temperature and vomiting.

She had been to the doctors three times in the past week and had been given antibiotics.

But upon arrival at the local hospital, the family had to wait 1.5 hours before Chanel was looked at.

“This has not been a major issue,” ruled Ms Forbes, citing that since 2008 emergency wait times at the hospital have significantly decreased.

But the main concern for the Costa family was the “hands off approach” by staff once a decision was made to transfer Chanel to a specialist children’s hospital after her condition deteriorated and she began suffering from seizures.

“When the on call paediatrician visited Chanel he ordered a serum ammonia test that can detect syndromes like Reye’s but the test was cancelled and he never visited Chanel to do a follow-up,” Mr Costa said.

At 8.50am that morning, the Newborn and paediatric Emergency Transport Service (NETS) was called to take Chanel to Westmead Children’s Hospital.

Mr Costa said his family was distraught that no NETS vehicle was available and there were significant delays.

They were also told that there were no beds at Westmead, forcing Chanel to be taken to the Sydney Children’s Hospital, Randwick.

“It was not until 10am that a NETS vehicle was dispatched for Chanel because there is only one team working at a time and the morning team was all the way in Wagga,” Mr Costa said.

 “NETS only had five vehicles, which was later increased to six, and the court found that the service cannot be criticised? They were understaffed and still are.

“And I am disgusted that the coroner said there were no beds available at Westmead – there were two available that day [though they were not informed of this at the time] and the registrar has documents to prove it.”

When Chanel was finally transferred to Randwick it was too late – in the transport vehicle her condition took a turn for the worse. When she arrived at the hospital she was rushed into intensive care for surgery to reduce rising intracranial pressure, but on the operating table she slipped into a coma and never recovered.

Four-year-old Chanel passed away on July 18, 2008.

After the court decision was announced, Mrs Costa said her world had fallen apart.

“I lost my daughter, I lost my home, I lost my marriage, I lost everything,” she said.

Mr Costa added: “Nothing is different to when we started three and a half years ago on this journey. All I can say to the parents of Australia is don’t waste your time. Go straight to Randwick or Westmead.

“Our daughter may still be here today had we made that decision ourselves, especially when NETS said to my wife in the ambulance, ‘you should have gone straight to Westmead’.”

Hoping that Chanel’s death may still somehow make a change to the health system so no other family has to endure the same trauma, Mr Costa is calling for additional funding for Nepean Hospital.

“The court doesn’t want to open this can of worms but we will keep fighting – we are determined,” he said.

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