Police have referred the death of Balgowlah toddler Joe Massa to the NSW Coroner and launched an investigation after allegations surfaced that Northern Beaches Hospital reportedly failed to provide life-saving treatment.
Emergency Visit Turns Tragic
Elouise and Danny Massa took their son Joe to Northern Beaches Hospital’s emergency department on 14 September 2024 after he spent the night vomiting. The toddler had hypovolemia, a condition caused by severe fluid loss. Despite a dangerously high heart rate of 183 beats per minute, Joe was reportedly misclassified as a Category 3 patient instead of a more urgent Category 2.
His condition allegedly deteriorated over three and a half hours as his mother’s pleas for an IV drip were ignored. Joe suffered a fatal heart attack at 10:47 a.m. and later died at Sydney Children’s Hospital in Randwick due to brain damage.
Hospital Failures Revealed
A Serious Adverse Event Review (SAER), submitted to the NSW Health Ministry in December 2024, identified multiple failures in Joe’s treatment, including:
- Failure to recognise and respond to a critically high heart rate.
- Ignoring parental concerns about their child’s worsening condition.
- Failure to act on internal escalation procedures.
- Lack of an automatic alert system in the hospital’s patient IT system.
- Two clinicians involved in Joe’s care were referred to the hospital’s executive unit for further management.
New developments have now escalated the matter.
Police and Coroner Step In
Following widespread media coverage and a NSW Parliamentary Inquiry into the incident on 27 February 2025, NSW Police announced they had retrospectively reported Joe Massa’s death to the NSW Coroner.
A police spokesperson confirmed on 28 February that Strike Force Carlton has been established to investigate the circumstances surrounding Joe’s death.
“Police have been directed by the NSW Coroner to investigate the death of a two-year-old boy from Sydney’s Northern Beaches in September last year,” NSW Police said in a statement.
Authorities also confirmed that the death had not been initially reported to police.
“More Fluids?”
During a NSW Parliamentary Inquiry on 27 February, Northern Beaches Hospital’s Chief Medical Officer, Peter Thomas, reportedly admitted that Joe Massa should have received fluids earlier.
“Retrospectively, it would’ve been appropriate to give baby Joe fluids earlier in his admission,” he told the enquiry.
The NSW Coroner’s findings and the police investigation may determine whether further action is taken against the hospital or medical staff.
Community and Political Response
Joe’s parents have called for a full public review of Northern Beaches Hospital’s emergency department and greater oversight of the public-private partnership (PPP) model that governs the facility.
NSW Health Minister Ryan Park admitted the hospital allegedly failed the Massa family. Official Chris Minns acknowledged the tragedy, stating that the government was open to further inquiries and potential policy changes.
Meanwhile, Dr Sophie Scamps, a former emergency doctor at Mona Vale Hospital, condemned the hospital’s PPP model, calling it a “failed experiment.” She launched a petition demanding the hospital be returned to public hands, which has already gathered over 1,500 signatures.
Photo Credit: Pexels
Implementation of ‘Joe’s Rule’
In response to the tragedy, NSW officials will overhaul the existing “REACH” protocol, which allows families to escalate concerns about a patient’s deteriorating condition. The new system, to be renamed “Joe’s Rule,” aims to simplify the escalation process and ensure all families are aware of their rights.
The State have also committed the following:
- Investigating Joe Massa’s case further through a coronial inquest.
- Reviewing the Northern Beaches Hospital’s emergency department procedures.
- Examining its contract with private hospital operator Healthscope.
Northern Beaches Hospital’s Controversial Public-Private Model
The Northern Beaches Hospital opened in 2018 under a PPP model. It replaced the public Manly and Mona Vale hospitals, a move that was widely opposed by residents. The state provides ongoing funding to private operator Healthscope, now owned by Canadian investment firm Brookfield.
A 2020 NSW Upper House inquiry into the hospital highlighted operational concerns and recommended ending all future PPP hospital arrangements in NSW. Five proposed regional hospital PPPs were scrapped as a result.
Public Outrage and Calls for Action
Many Northern Beaches residents have renewed calls for an entire public emergency department to be reinstated at Mona Vale Hospital. Former staff have reportedly raised concerns about chronic under-resourcing at Northern Beaches Hospital, with some nurses describing allegedly unsafe working conditions and staff shortages.
Patients have also allegedly experienced delays in emergency care, with some choosing to seek treatment at Royal North Shore Hospital instead.
What Happens Next?
The Massa family remains committed to seeking justice for their son. They continue to push for:
- A full independent review into Northern Beaches Hospital’s emergency department.
- Mandatory patient IT system upgrades to escalate critical cases automatically.
- Legislation banning public hospitals from outsourcing operations to private companies.
Mr Minns stated that he would look into further investigations, and the NSW officials will soon hold a roundtable discussion on hospital reforms. The introduction of “Joe’s Rule” marks the first step towards ensuring no other family experiences a similar loss.
With the launch of Strike Force Carlton and the involvement of the NSW Coroner, the case has now entered a critical new phase of scrutiny.
Published 3-March-2025
