A Sydney hospital has admitted it was a "catastrophe" when a 10-month-old baby died after a catheter pumping antibiotics invaded the right side of his heart.
But since Tama Galiere's death in June 2008, Sydney Children's Hospital has led reforms to the way catheters are administered across NSW.
Tama was in the Randwick-based hospital to undergo antibiotic treatment for a severe eye infection.
However, he died on June 25, 2008 when the catheter migrated into the right ventricle of his heart.
An inquest has looked into Tama's death, including whether the hospital's treatment was appropriate.
In his findings delivered on Friday, NSW Deputy State Coroner Hugh Dillon said Tama was a healthy little boy, except for his recurrent eye inflammation.
He found while while there was a number of complex medical issues in the case, at its heart was a sad and tragic human story.
Doctors inserted a peripherally inserted central catheter (PICC) into Tama after difficulties with an earlier method.
The PICC came with a warning from the manufacturer that leaving the catheter in the heart's right ventricle could result in patient death.
During the inquest, Dr Matthew Crawford, who administered the catheter, said if the process was done with adequate care, he didn't expect there to be trauma or inflammation.
However, six years on, expert evidence during the inquest was that the technique should be avoided.
The coroner found it was most likely the catheter moved into the heart ventricle when a dressing, applied where Tama's catheter was inserted, was changed.
"If the catheter was left unsecured, even for a short interval, this seems the last likely time for it to have migrated," Mr Dillon stated in his findings.
However, no one at the hospital owned up to changing the dressing.
Mr Dillon said a hospital director had told the inquest that Tama's death was a catastrophe.
Mr Dillon said the tragedy led to a new policy on insertion and post-care of central lines in hospitals across the state.
Outside the Glebe Coroner's Court, Tama's mother, Karamia Wheaton, said her family was happy with the findings, but expressed her continuing grief.
"We feel let down by what happened at the hospital," she said. "He was our angel, he was beautiful."
The family and Maurice Blackburn lawyers are considering legal action against the hospital.
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