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A severely ill toddler who died of meningitis was discharged from a regional Victorian hospital in a worse condition than when he was admitted, a coroner has heard.
An inquest is investigating the death of 19-month-old Noah Souvatzis who had been holidaying with his parents in Myrtleford on December 29, 2021, when he became unwell, vomiting, crying for hours and had a high fever.
Unable to secure an appointment with their local GP in Melbourne, his parents Ben and Steph decided to take him to an urgent care centre in town after he became severely lethargic, unable to keep fluids down and unresponsive.
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The family arrived at the Alpine Health clinic where they spent most of the time waiting in a shipping container as the state's health system battled the COVID-19 pandemic.
The nurse at the facility monitored Noah's vitals and noted symptoms of lethargy, being alert at times but had increased heart and breathing rates and was unable to keep fluids down.
"He was very different that day, making groaning noises," Souvatzis said.
"It was not the same as a cry. It was a high-pitched, a whimpering noise, like he was in pain."
Fearing Noah's condition was deteriorating, nurses told Noah's parents to take him to Wangaratta Hospital, which had a pediatric department.
During the trip, Souvatzis recalled trying to rouse her son who was uncharacteristically dozing off but still vomiting and heaving despite nothing coming out.
Upon arrival, the Souvatzis' were concerned seeing the "disorganisation and panic" by Northeast Health Wangaratta staff who were responding to COVID-19.
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"It didn't fill me with great positivity that they were going to take care of my son adequately. But what other options did we have?" Souvatzis said.
Noah was attended to by a new doctor who diagnosed the child with viral gastroenteritis and monitored him over the three-hour stay.
Despite his vitals returning to a normal range, Souvatzis said her son remained lethargic, limp, unresponsive and unable to take in fluids.
"I played a Wiggles song on my phone. Noah loved The Wiggles. They were his life," Souvatzis said.
"He didn't even seem to acknowledge the sound."
Despite Souvatzis' concerns that her son was still unwell, the doctor made the decision to discharge Noah.
"I remember feeling relief Noah had started vomiting again … because I thought it would mean (the doctor) would no longer make us leave."
Noah was discharged anyway.
"He looked awful. He was pale. He could not keep his head up and would flop all over the place," Souvatzis said.
"He was sick when he went into hospital but now he deteriorated. He was so much worse than before he came in."
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His parents took him to a motel but rushed him to the urgent care centre in Benalla after he began making strange squealing noises and his face became distorted.
Nurses and GPs ordered Noah to be urgently transferred back to Wangaratta Hospital and he began suffering seizures on the trip there.
He was rushed to the Royal Children's Hospital after he further deteriorated and was diagnosed with bacterial meningitis.
At 3.11pm on December 30, Noah was declared brain dead.
Outside the Coroner's Court, Noah's parents remembered their son as a beautiful, gentle boy who loved cuddles and making others laugh and smile.
"We want a comprehensive investigation into the multiple failures that occurred that day," Souvatzis told reporters.
"We want to prevent what happened to Noah from happening to other Australian kids.
"We know our little boy would still be here today if all the medical services provided the expected level of care."
A Northeast Health Wangaratta representative on Monday conceded the care provided to Noah was not appropriate during his first presentation and apologised to his family.
