'I am sorry': Government apologises for death of Rozalia Spadafora in TCH

The ACT Government has apologised for failings in the healthcare offered to a seriously ill child.

Five-year-old Rozalia Spadafora and her family arrived at The Canberra Hospital’s emergency department at about 7 pm on 4 July 2022.

She would die at The Canberra Hospital (TCH) on 5 July 2022. Her death was caused by a heart condition, myocarditis, brought on by an influenza A infection.

A coronial inquest into the circumstances surrounding Rozalia’s death started in October 2023.

When Coroner Ken Archer handed down his findings in December 2023, he said healthcare provided to Rozalia was too slow and hampered by miscommunication between staff.

On Wednesday (5 February), ACT Health Minister Rachel Stephen-Smith teared up as she gave the government’s official response to the inquest.

She said Rozalia’s mother, Katrina Spadafora, did “as much as any parent could be expected to do to seek healthcare and advocate for Rozalia”.

“Katrina repeatedly sought care when Rozalia was unwell and had a right to expect that the health system would respond with the best possible care,” she said.

“I am sorry that Canberra Hospital let her and Rozalia down so badly.”

Ms Stephen-Smith apologised on behalf of the ACT Government and Canberra Health Services for “shortcomings that robbed Rozalia of any chance she may have had for survival”.

She said the government had accepted all four recommendations raised in Coroner Archer’s inquest.

One recommendation was that Canberra Health Services (CHS) appoint a Clinical Initiatives Nurse (CIN) on a 24-hour roster, whose role would involve continually monitoring and assessing patients after they were triaged.

The CIN role at TCH existed when Rozalia was admitted, although the inquest found it was unclear why the CIN didn’t follow up on why Rozalia wasn’t seen within the expected timeframes after being triaged.

Ms Stephen-Smith said that the CIN’s role had been expanded since December 2024, and electronic rostering is now used to ensure the position is filled.

“[Following the recommendation] CHS has introduced a policy which commits to the rostering of the clinical initiative nurse in the Canberra Hospital, 24 hours a day, 365 days a year,” she said.

She also said the Digital Health Record was being used to ensure efficient and accurate ongoing patient care, and Coroner Archer recommended that its use be examined.

“At the time of Rozalia’s presentation, CHS was using about 40 electronic systems to manage the clinical care of patients, as well as relying on paper-based forms,” she said.

The government was also working to promote influenza vaccines for young children, in line with another recommendation.

Ms Stephen-Smith added that additional paediatric emergency specialists had been recruited, and staff were offered further training in caring for ill children.

Speaking in the Legislative Assembly, Ms Stephen-Smith said the ACT Government acknowledged “the inconsolable grief” Rozalia’s family continued to live with.

“I can only assure them that the ACT Government will not forget what happened to Rozalia. Her death and the deficiencies in her care have led to significant improvements in the systems and processes at Canberra Hospital,” she said.

“We are committed to ensuring that no other family experiences what Rozalia’s mother, father, brother, grandparents and broader family and friends have been through.”

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