Doctors did not respond to a child's life-threatening test result, a nurse has told an inquiry.
On Monday, registered nurse Sarah Retford spoke at the coronial inquest of Rozalia Spadafora, a five-year-old who died at Canberra Hospital in July 2022.
Ms Retford said she found the result of a troponin test, which revealed Rozalia was seriously ill, on a sticky note in the little girl's files on the morning of July 5.
The court previously heard that pathology would call a ward to notify them of urgent results, and a ward clerk would pass a doctor that information via a paper slip.
Pathology results were also available on a computer system.
"I'd seen results written on post-it notes before [but not stuck in a patient file]," Ms Retford told the court.
Ms Retford said she thought maybe clerical staff member not aware of the significance of the result couldn't find a doctor and so placed it in Rozalia's file, notes placed on a table at the foot of her bed.
The nurse said she informed several other nurses of the result, before moving Rozalia to a different bed, which she had been asked to do.
This was some time after 8am that morning.
"Minutes" after moving Rozalia, Ms Retford said she informed two paediatric doctors, Dr Jade Stewart and Dr Aidan Watters, of the troponin result.
Dr Stewart said to call if Rozalia got any worse and left, Ms Retford told the court.
Ms Retford said she called Dr Stewart when Rozalia returned from an ultrasound around 11.30am looking very sickly.
The court heard Dr Stewart said she only found out about the troponin result after overhearing a conversation between Ms Retford and another nurse, Lucinda Reumer.
Dr Stewart and Dr Watters are expected to give evidence to the inquiry on Tuesday.
Rozalia moved wards
Senior nurse Analiese Vartiainan was working in the resuscitation bay on the morning of July 5, and was responsible for Rozalia.
She said earlier in the morning, an emergency doctor told her Rozalia could be moved.
Ms Vartiainan said she knew several emergency patients would be coming to the resuscitation bay, and was concerned Rozalia would not get enough attention from nurses.
"It wasn't a question of space, it was a question in my mind of resources available," she told the court.
She said she moved Rozalia to the paediatric emergency department because Ms Retford, a nurse in that ward, was well-trained enough to care for the little girl.
Ms Vartiainan said she was not aware Rozalia's observation charts showed her condition had deteriorated, particularly her blood pressure.
The nurse said she would have kept Rozalia in the resuscitation bay if she had known, and notified a medical officer.
Ms Reumer and Ms Retford said they checked Rozalia's vital signs when she arrived in their ward at about 10.20am.
Ms Reumer said after discovering Rozalia had a poor health score, calculated by looking at vital signs, she followed protocol and contacted a paediatric doctor.
This was an hour before Ms Retford said she called Dr Stewart and the situation was escalated.
The inquiry is expected to continue on Tuesday.
