STATE Coroner Michael Barnes delivered a damning report on the treatment Ryan Saunders received at the Rockhampton Base Hospital in 2007.
Mr Barnes found Ryan, who died of Group A Streptococcal Toxic Shock Syndrome on September 26, 2007, received "adequate and appropriate care" from his Emerald-based GP and medical staff at the Emerald Hospital.
But it was head of paediatrics at the RBH, Dr Peter Roper, that Mr Barnes said "overlooked" a number of issues, which, had they been addressed, may have saved the toddler's life.
Doctors failed to complete a septic work up at the RBH which would have triggered the administration of antibiotics.
"Had antibiotics been given at this stage, they may have saved Ryan's life by combating the Streptococcal infection the autopsy confirmed was the fatal agent," Mr Barnes said.
Expert witnesses told the inquest it was usual practise to complete a septic work up, but it was heard Dr Roper "had a very different approach" toward the treatment, and cited a number of symptoms which he testified Ryan did not have while in hospital.
But Mr Barnes found further toxic work up investigation was "called for".
He further found Dr Roper "had no basis on which to conclude" Ryan's parents, Donna and Terry Saunders, were reluctant for their son to receive further treatment.
"I consider this an attempt on his part to bolster what was otherwise an inadequate explanation for his failure to undertake these tests," he said.
"Despite urging from a number of junior doctors to order such tests, Dr Roper repeatedly made a serious error of judgement when he declined to do so."
Mr Barnes said the decision to withhold pain medication "justified the suffering it caused", and labelled it an "error of judgement on Dr Roper's part".
"The failure of Dr Roper to review Ryan in these circumstances is surprising but it is clear it had no impact on the outcome," he said. "I readily accept the progression of Ryan's condition from mild infection to life ending septic shock was rare and unusual. I have no doubt all of the practitioners involved in Ryan's care would act very differently if they were confronted with a similar case in the future."
Mr Barnes recommended no disciplinary action be taken against Dr Peter Roper, and commended Queensland Health's adoption of the Children's Early Warning Tool.
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