A New South Wales deputy state coroner has handed down three recommendations after finding there were "significant flaws" in the decisions made ahead of the untimely death of Broken Hill boy Austin Facer.
The six-year-old died from a cardiac arrest in the outback city's hospital in 2019 after waiting nearly 12 hours for a medical transfer.
Deputy State Coroner Elizabeth Ryan said there was "flawed decision-making" between South Australia's MedSTAR and the NSW Newborn and Paediatric Emergency Transport Service (NETS) in the handling of Austin's case.
"There were significant flaws in the planning for Austin's transfer, which led to unacceptable and avoidable delays," she said.
"There was a lack of clarity as to which service had ownership of Austin's transfer.
"This, together with sub-optimal decision-making, led to failures in communication and planning."
Magistrate Ryan said there was a clear breakdown in communication between the retrieval services, but there was no way of knowing if more timely action would have saved Austin's life.
"One of the questions at the inquest was that a speedier transfer would've made a difference for Austin's chances of survival," she said.
"In this inquest I have accepted it remains unknown.
"But there is no doubt a more timely transfer had the potential to improve his chances of survival."
A long wait
At about 11:40am on October 21, 2019 Austin had been playing at school before complaining to a teacher of severe chest and abdominal pain.
He was then walked to the office where he went into cardiac arrest for the first time, requiring resuscitation by school staff and paramedics.
Austin was taken to Broken Hill Hospital just after midday and tests were run before it was decided he should be medically evacuated to a larger hospital.
Timothy Bailey, the emergency physician on site, called the NETS and MedSTAR in SA to figure out who would transfer the sick student.
After almost half a day of miscommunication a NETS team arrived just after 11pm.
But Austin went into cardiac arrest again while he was being moved onto a stretcher just before midnight.
Despite rigorous attempts to resuscitate him, Austin was pronounced dead just after 2am.
Mum's heartbreak
In a statement from the family following the findings of the coronial inquest, Austin was remembered as a "happy" boy whose "big smile could light up any room."
His mother, Caroline Phillipson, slammed the medical retrieval services for their inaction in the hours before her son's death.
"I have heard the coroner's findings today and we are grateful for everyone taking the time to investigate Austin's death," she said.
"I would like to say we strongly believe in our hearts that if our little boy was transferred to a tertiary hospital he would have received the necessary care he so desperately needed.
"We would still have our little boy with us here today."
Ms Phillipson said she hoped no other family would ever go through what happened to her family.
"Having to bury your child and then try and soldier on without them is something I would never, ever wish upon anyone," she said.
Coroner's recommendations
Magistrate Ryan handed down three recommendations and highlighted the need to clarify the operational procedures and clinical processes between medical retrieval services.
"This guideline acknowledges the responsibility of NETS to remain involved and informed in the retrieval process, [including] up to the point where the relevant retrieval team collect the patient from Broken Hill based hospital," she said.
The second recommendation related to improving the method of exchanging a patient's clinical information.
The final recommendation made by the coroner focused on the need for important documents and procedures to constantly be updated to provide the best possible care for patients.
"My third recommendation goes to the need for a particular document called a 'model of care' to continue to be revised to incorporate guidance and responsibilities and the role of NETS, medical roles and consultants," Magistrate Ryan said.
The ABC has reached out for comment from both NSW Health and the Far West Local Health District.
The ABC was granted permission from the family to publish a picture of Austin.
