No closure for family
SEPTEMBER 26 will always be the hardest day of the year for Donna and Terry Saunders.
But following the conclusion of the inquest into their son's death, knowing the tragic circumstances will never be repeated, will go some way to relieving some of pain they feel each day.
"It's been a long four days, a long four years, but I think the family is a little more at ease now that we can see some things have been put in place," Ryan's uncle Grant Kerlin said yesterday after the last evidence was heard.
"There have been some things recommended that will go a long way to preventing this in the future.
"These are a few things that have been done that are now Ryan's legacy."
Four days of gruelling testimony in a Rockhampton courtroom brought to the surface the painful sequence of events that four years ago, ended in their son's death.
Suggestions that intimidated staff were reluctant to press for pain medication to be given to Ryan, who, the inquest was told, could be heard crying throughout the pediatric ward, remained a prominent point.
Rockhampton Base Hospital head of paediatrics, Dr Peter Roper, said in his sworn evidence on Tuesday he withheld morphine for fear it would mask crucial diagnostic symptoms.
But his claims were countered by other medical professionals who were called for their expert opinion.
Toowoomba Hospital pediatric consultant Dr Jeffrey Prebble told the inquest Ryan's killer, Group A streptococcus toxic shock syndrome, was the worst case of the disease he had ever seen.
He said when he sought to investigate it further, medical textbooks and journals had no reference to the condition, a core issue identified by the Health Quality and Complaints Commission in its 16 recommendations.
Dr Prebble said he could not recall a single instance in his time as a doctor at a hospital or in private practice when a nurse or another doctor suggested a test be done, that it was denied.
"It would have been reasonable to perform that test," he said, when asked if Ryan's symptoms warranted a blood culture test be done at the time of the lumbar puncture.
"If they (a doctor) thought a consultant's recommendation was inappropriate, a discussion should be held.
"In my practice, if they (junior doctors or nurses) feel that the test should be done, they will do it.
"They are qualified medical practitioners and are able to do so."
It was recommended Queensland Health implement a system in which nursing staff and junior doctors feel comfortable in questioning senior staff when a test they believe is crucial is denied.
But it was when Patient Safety and Quality Improvement Service director, Dr John Wakefield explained the Children Early Warning Tool to the inquest that the stoic Saunders wept.
CEWT is a multi-million dollar IT system being rolled out in hospitals around the world, and uses a colour coding and graphing system to map a patient's health history and deterioration.
It works on a numerical score where the higher the number, the more urgent the attention required after all monitoring factors have been analysed in the system. The colour coding will prompt doctors to act, where green indicates the patient is relatively okay, but orange and red require further tests and immediation treatment, respectively.
"I think with Queensland Health, with the recommendations they put forward, the most significant thing they put through was the CEWT system," Mr Kerlin said.
"For someone who has no medical knowledge, it just seems like a really good tool.
"It addresses a number of issues we've had over the past four years."
The inquest also heard had antibiotics been given to Ryan sooner, particularly when his temperature of 37.6 degrees and heart rate of more than 110 was recorded, his death may have been preventable.
Dr Prebble said a child patient with a recorded heart rate of 175 beats per minute is "an alarm bell that says this child is not well". However, he conceded it would not assist him "in specifying where the problem was".
The four expert witnesses called to testify, each with vast medical experience, said it was easy to comment "in retrospect" and "in hindsight".
Pediatric cardiologist Dr Gavin Wheaton told the inquest he believed the outcome of medical cases influenced how they were thought about.
"Whenever we review events in hindsight this way, it is often very easy to see that things perhaps should have, or could have, been done in a certain course of events," he said.
But there is no hindsight for Ryan's family, and instead they are working to make sure some positive comes from his death.
"There'll never be closure. We miss our little boy," Ryan's father Terry Saunders said.