The parents of a three-year-old boy, who died of influenza A in Sutherland Hospital, hope lessons will be learnt from the tragedy.
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Aidan Mara died in July 2014, two days after he was admitted suffering symptoms of pneumonia.
A coroner found on Friday that, when monitoring equipment did not seem to be working, nurses became “fixated” on the machine instead of physically questioning whether the child was critically ill and manually checking he was alive.
Deputy State Coroner Teresa O'Sullivan recommended training for all nurses to change a culture she said relied upon monitoring equipment rather than basic nursing skills.
After the findings, Aidan’s father Lucas Mara said, “To make change we need to be aware of things that have gone wrong, and put our hands up when things do go wrong”.
Mr Mara appealed to parents to ensure their children were vaccinated.
Aidan, who died within three days of becoming ill, had “collapsed really, really quickly once he got the flu”, Mr Mara said.
“We actually didn't really know he had the flu until after he passed away,” he said.
Aidan's immunisations were up to date, but he didn't have the non-compulsory flu shot.
“Regrettably, if we had known we probably would have got the vaccine for Aidan,” Mr Mara told Seven News.
“As a parent that's a bit hard to take.”
The inquest heard Aidan died two days after he arrived at Sutherland Hospital “very unwell”.
The toddler's condition fluctuated during that time and on the morning of his death he was more alert and “interested in eating and drinking”.
But things got worse when a decision was made to shower a soiled Aidan after his catheter was removed.
Two nurses - one of whom had worked at the hospital for more than 20 years - decided to take out his oxygen nasal prongs “without any great thought” or consultation with the medical team.
Ms O'Sullivan said it was “understandable” that a quick decision was made to disconnect him given he was distressed.
“It is clear, however, that the decision to do so was an error,” she said.
“I am not satisfied that any close attention was paid.”
At the end of the shower, Aidan collapsed and was returned to bed.
The nurses reattached the oxygen and monitoring sensors but were unable to get adequate readings. They spent some time checking the machine thinking it was faulty.
Aidan appeared to fall asleep a short time later but the boy's grandmother noticed he was not breathing and his lips and chest were cold.
Ms O'Sullivan concluded the “nurses fell into error in focusing too long on the monitoring equipment without checking the physical signs of whether Aidan was breathing.
“There is sufficient evidence that the time between Aidan collapsing and the time of calling for medical review was unacceptably long, as a result of the fixation on the monitoring equipment, which the nurses thought must be the cause of the failure to get adequate readings,” she said.
“The nurses were convinced that the monitoring equipment was faulty rather than questioning whether Aidan was critically ill and using basic manual checks.”
Both nurses admitted to the inquest they made errors. Neither recalled having received training about how to avoid “fixation errors”.
Ms O'Sullivan recommended that a component of training for nursing staff address the phenomenon relating to the assessment of results of monitoring equipment.
The coroner noted hospital staff were “deeply saddened” by Aidan's death and the local health district had proactively made a number of changes as a result.
