No warning, 12-year-old guidelines and a long shift: The litany of problems before Joe Massa’s death

The registered nurse who triaged a two-year-old who died at the Northern Beaches Hospital has told a coronial inquest she had no alert about his abnormal heartbeat, was working with 12-year-old guidelines and was finishing a long shift during which she had been assaulted.

NSW State Coroner Teresa O’Sullivan is examining the litany of problems at Northern Beaches Hospital that led to Joe Massa going from playing peek-a-boo to entering cardiac arrest within a day.

The toddler’s death shocked Sydney and led to the hospital, which was previously run by the private operator Healthscope, to be transferred into public hands . His mother Elouise Massa’s advocacy following his death also led to “Joe’s Law” , which bans future public-private partnerships.

Massa gently stroked a tiny pair of her son’s shoes as she gave evidence on Monday, the first day of the inquest. She said clinicians at the hospital were rude and did not listen to her concerns as Joe’s condition rapidly deteriorated.

Massa took Joe to the Northern Beaches emergency department about 7am on September 14, 2024, after she became concerned about his severe vomiting and dry retching overnight.

“He looked terrible,” she said. “He could barely keep his head up, he was going in and out of consciousness, he was floppy.”

She told the court she had “a mother’s instinct” that something was “very wrong”.

Joe was triaged as a category three patient who required treatment within 30 minutes, despite having a “red zone” heart rate of 182 beats per minute.

The registered nurse who triaged Joe, Hilary O’Neill, said she saw the toddler at the end of a 12-hour overnight shift without a proper break, during which she said she was assaulted by a mental health patient, who threw her against an ambulance door.

O’Neill said the only reference she had to assess Joe’s heart rate was a resuscitation guideline from 2012.

The system informed her Joseph was one year old – he was aged 22 months – and she assessed his initial heart rate of 160-170 BPM as just above the normal range.

She did not re-check the guide after he later recorded the higher heart rate.

“There were no track or trigger systems in place to alert me that it was in the red zone,” she said.

The inquest heard that in the public hospital system, clinical software would have automatically flagged that the reading was outside normal parameters, and notified all staff who reviewed the patient file.