DONNA and Terry Saunders want to make sure that what happened to their two-year-old son Ryan on September 24, 2007, never happens to another child.
That is their hope as they sit and listen to the raw testimony of medical staff during the week-long coronial inquest into their son's tragic death at Rockhampton Hospital.
"This will be worth it if it never happens again," Mr Saunders said, outside the courthouse yesterday.
"That's what we want, as hard as this is, something has to happen."
Mr Saunders' comments follow the testimony of four medical staff responsible for Ryan's treatment after he was airlifted from Emerald Hospital.
He was initially diagnosed with a twisted bowel, and because Emerald did not have an ultra-sound machine the decision was taken to transfer him.
Ryan died of toxic shock syndrome 24 hours later.
Doctors in Rockhampton first suspected Ryan had a viral infection, but subsequent tests raised differing diagnoses from staff.
The inquest was told Ryan was left crying in agony in an isolation room on the hospital's paediatric ward for more than four hours as the department head, Dr Peter Roper, refused to administer any pain relief.
Hospital registrar Dr Pauline Higgins cried as she recalled that the "child was in pain".
"I don't recall if I heard him cry, but he just looked like he was in pain," she said.
The inquest heard a lumbar puncture test was performed, although it was common practice for a blood culture be completed first as it was less intrusive. But the negative results clarified that Ryan was not suffering meningitis, as originally diagnosed, and more tests were ordered.
Dr Higgins said after Ryan's death, the staff on duty met off hospital grounds to discuss the events to determine what happened.
Under cross examination, she revealed she had concerns about her own conduct on the day.
"(Dr Roper) said, 'we all make mistakes and it was a difficult case'," Dr Higgins said.
"I never realised how sick he was. Obviously we should have treated his pain better."
Primary health officer Dr Nasreen Kamal said Ryan's abdomen was tender, and "he was guarding it" during the examination.
She suggested to Dr Roper an IV fluid drip be administered to take more blood samples but he thought the condition was viral, not bacterial.
Dr Kamal told the inquest she believed Dr Roper withheld pain medication in case it masked Ryan's symptoms, but said it was unjustified at a hospital with modern technologies.
The inquest also heard from Dr Gezina Roos via telephone link, and nurse Rosaline King who said she could hear him crying "in the hallway".
The inquest before Coroner Michael Barnes continues today.
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