The parents of a 19-month-old boy who died after being wrongly discharged from hospital have sobbed in court as a coroner found his death was preventable.
The Souvatzis family were holidaying in Victoria's northeast on December 29, 2021, when Noah developed a high fever and started vomiting.
His parents Ben and Steph took him to an urgent care centre in town, with a nurse at the Alpine Health facility noting symptoms of lethargy and increased heart rate.
Noah was taken to the Wangaratta Hospital on the nurse's advice, where doctor Paul Bumford diagnosed him with gastro and discharged him three hours later despite his continued vomiting.
Noah's condition worsened so his parents took him to another medical centre in Benalla a couple of hours later, with Noah then taken by road ambulance back to Wangaratta Hospital.
The young boy suffered seizures on the drive there and CT scans showed signs of meningitis so Noah was flown to Melbourne's Royal Children's Hospital in the early hours of December 30.
At 3.11pm that day, Noah was declared brain dead and he died the following morning.
Coroner Katherine Lorenz on Tuesday found Noah's tragic death was preventable and he should not have been discharged from Wangaratta Hospital in the first place.
"It was a clear failure of Wangaratta Hospital's duty of care to Noah," Ms Lorenz said.
Ben and Steph Souvatzis sobbed in the Coroners Court as the findings were handed down.
Ms Lorenz noted Dr Bumford was on his first shift at the hospital and in the middle of an induction session when he went to assess Noah.
He was meant to be second-in-charge at the emergency department but was not experienced enough for the role, the coroner found.
The more experienced senior doctor Doug Devereux should have assessed Noah or at least examined his medical records before allowing him to be discharged, Ms Lorenz said.
But Dr Devereux gave Noah "no more than a glance" even though photos from the day show Noah was clearly very unwell and not alert, the coroner said.
Dr Bumford conceded during the inquest that he misdiagnosed Noah and the coroner found the toddler might have survived if he was given antibiotics at his first hospital presentation.
Ms Lorenz also Noah's outcome might have been different if the doctors listened to Ben and Steph Souvatzis when they raised concerns about their son's condition.
"Parents know their children best," she said.
The coroner recommended the Australian Commission on Safety and Quality in Health Care and Safer Care for Kids consider advising doctors to ask and note parental concerns when routinely checking a child patient's vital signs.
Ms Lorenz commended the Souvatzis family for their courage in pursuing an inquest in the face of a heartbreaking and life-altering tragedy.
The couple did not speak to reporters but made a statement through their lawyer in court, thanking the coroner for listening to them after years of not being heard.
A Northeast Health Wangaratta spokeswoman said the hospital's thoughts and condolences continued to be with the Souvatzis family.
"NHW accepts that Noah did not receive the care he should have, something that rightly weighs very heavily on us as a health service," the statement to AAP read.
"We thank the coroner for their findings, which we will now review and we are committed to implementing any further improvements."
