Rozalia Spadafora's mother's collected manner broke just once as she recalled the last day of her daughter's life.
"What was the last thing she said to you?" counsel assisting, Michael Fordham SC, asked Katrina Spadafora in the coroners court on Wednesday afternoon.
"She just called my name," Ms Spadafora recalled, her eyes welling.
Earlier in the inquest into the death of the five-year-old at Canberra Hospital, a lawyer said there appeared to be a series of "missed opportunities" to potentially save her life.
Ms Spadafora outlined to the court what happened on Rozalia's last day on July 5, 2022, before she went into cardiac arrest and could not be resuscitated.
She said a doctor said Rozalia's veins were too small because of dehydration, causing the doctor difficulties in trying to take a blood test.
Ms Spadafora said she that while there was a lot of focus from medical professionals on Rozalia's fluid intake, "I didn't think it was dehydration, I thought it was something more serious."
At a second review, a doctor did not examine Rozalia, the mother said. She said the doctor took Rozalia's blood pressure and told the mother it was a little bit low.
At this point, Rozalia's skin was cold to the touch, the mother recalled.
Between Rozalia being treated by this doctor and a paediatric consultant, Rozalia had been moved to a resuscitation bed.
At some time between 7am and 7.30am, the paediatric consultant examined Rozalia. Ms Spadafora doesn't recall the doctor ever touching Rozalia, but did see stickers, which may indicate an ECG was performed.
She doesn't remember a doctor being in the vicinity, but remembered a female nurse while the stickers were on her daughters chest. No one informed Ms Spadafora about the result of the ECG, she said.
Rozalia was "extremely quiet" and lethargic. Other than "mummy, I want to go home," the child said very little, her mother recalls.
The paediatrician said she was waiting for Rozalia's blood test and chest x-ray, Ms Spadafora recalled.
"She did explain to me she was dehydrated," Ms Spadafora said.
At about 7.30 or 8am on July 5, Ms Spadafora said she was informed test results confirmed Rozalia had influenza A, that she was dehydrated and would be in hospital between two to four days.
Mr Fordham suggested earlier in the inquiry that increasing fluids may have actually made Rozalia's myocarditis worse.
Diuretics, drugs that reduce fluid congestion in the body, are sometimes used to treat myocarditis.
The morning of the little girl's death, a doctor told Ms Spadafora that Rozalia's liver was enlarged. Ms Spadafora said it was the first time she had heard this.
About 10.30am, the doctor performed an ultrasound on Rozalia's liver to find out why it was enlarged, Ms Spadafora recalled.
After Ms Spadafora returned from a bathroom break, Rozalia and her grandmother were "missing".
While one nurse told Ms Spadafora "I don't know who you're talking about," when she asked where her child was, another took Ms Spadafora to the paediatrics room where Rozalia had been moved.
No one had told Ms Spadafora about a possible move, she said.
Rozalia was in the paediatric bed for about 20 minutes before getting an ultrasound, and returned for about 30-60 minutes, the mother remembered.
No one mentioned the results of the ultrasound on the liver, Ms Spadafora said.
She did not remember the words myocarditis, cardiac or heart failure being used while in hospital.
"Was it made clear to you that there was an issue with inflammation of the heart?" Mr Fordham asked.
"Yes," Ms Spadafora said.
She said she was told Rozalia may need to go to Sydney as Canberra Hospital did not have the ability to treat her.
At some point, Rozalia was moved from the paediatric bed back to a different bed in the resuscitation ward, Ms Spadafora said.
Rozalia stayed there until being moved to the intensive care unit at about 3pm.
A doctor told the mother he "needed to put a cannula under [Rozalia's] collarbone" on the left side "to get some drugs into her heart to stabilise her".
Ms Spadafora had told been told by the consultant paediatrician that she was making phone calls to the newborn and paediatric emergency transport service (or NETS).
Mr Archer would later comment it was tragic that any parent should learn that term.
While doctors wanted to intubate Rozalia to take her to Sydney, it appeared what Mr Fordham called the "window of opportunity" for Rozalia to be stabilised and transported interstate had passed.
"She was very restless, she was getting very cranky ... she was moving her arms, very restless, and just asking for mummy, 'I want water'," Ms Spadafor recalled of the hours before Rozalia's death.
When Rozalia went into cardiac arrest, Ms Spadafora and her mother were taken to another room.
Rozalia was reported dead about 10.50pm, about 28 hours after she had arrived at the emergency department. The resuscitation effort took about 68 minutes.
The inquest will continue on Wednesday.
