Perth hospital workers missed the indicators a seven-year-old lady was dying of sepsis due to the pressures brought on by “inadequate” staffing, a coroner has discovered.
Premier Mark McGowan has insisted the hospital was not understaffed on the evening Aishwarya died as a result of it had its full rostered complement.
But in her long-awaited written findings on Friday, Deputy State Coroner Sarah Linton mentioned whereas that was “technically” right, it had been made obvious the roster had been insufficient to cope with demand.
“Aishwarya’s parents brought their daughter into hospital because they knew she needed help,” Linton mentioned.
“But due to the pressures on them, the medical and nursing staff missed the signs that she was critically ill from sepsis and failed to rescue her.
“It actually is as easy, and as tragic, as that.”
Linton did not make any individual adverse comment against the staff members involved in Aishwarya’s treatment.
The coroner has formally backed several recommendations put forward by the Australian Nurses Federation.
These include the priority implementation of nurse to patient ratios without waiting for an industrial agreement between the union and state government to be registered.
Linton has also recommended enhanced waiting room protocols to provide better monitoring of signs of sepsis, better access to digital record-keeping tools and the staffing of a standalone resuscitation team in the Perth Children’s Hospital ED.
She noted there were multiple opportunities on the night where clinicians could have escalated Aishwarya’s care, had they stopped to consider her symptoms more closely and listen to the repeated concerns being raised by her parents.
The “most vital” arose when junior waiting room nurse Tahnee Vining observed Aishwarya to be grunting in pain with an elevated heart rate, respiratory rate and temperature.
Vining did not consider sepsis, despite Aishwarya meeting the documented threshold for further investigation.
The nurse was unable to monitor Aishwarya because she was repeatedly called away on other duties, including assisting a patient resuscitation.
Had proper treatment been initiated during that time, there was a “small risk” Aishwarya’s life might have been saved, Linton said.
“That probability, albeit statistically small, was enormously vital to Aishwarya’s household.”
A nurse had raised concerns in an email to their union in March 2021 about the hospital’s staffing levels, and Linton said it appeared then-health minister Roger Cook had also been generally informed of the situation.
“It is deeply regarding to then see these occasions play out just a few days later, precisely because the nurse had feared,” the coroner said.
“The background factors to systemic points surrounding the resourcing of the ED, somewhat than the behaviour of people on this case.”
While the state government had implemented various changes to improve Perth Children’s Hospital, it was too late for Aishwarya and her family.
“It should not take the dying of a beloved little lady for… the federal government to cease and take into account what extra it may well do, and the way way more cash it ought to spend, to maintain kids secure once they go to our specialist kids’s hospital,” Linton said.
“There is not any level in having a cutting-edge facility, if the workers working inside it are stretched past capability and oldsters lose their belief and religion in them.”
Linton paid tribute to the “grace and dignity” of Aishwarya’s father Aswath Chavittupara and mother Prasitha Sasidharan, adding that she understood why they would “by no means forgive” the health system.
TIMELINE IN THE HOSPITAL DEATH OF AISHWARYA ASWATH
- Seven-year-old Aishwarya attends the last day of the school term. She plays soccer with her father Aswath in the evening and they walk to get icecream.
- Aishwarya complains of a headache. She vomits several times. Her parents give her Panadol and fluids.
- Aishwarya wakes up complaining of limb soreness. She appears very weak and suffers diarrhoea but manages to have some cereal and hydrolyte.
- 5.00pm – Aishwarya’s mother Prasitha notices the girl’s hands are unusually cold. The family decide to go to hospital
- 5.32pm – Aishwarya and her family arrive at the Perth Children’s Hospital emergency department. She is observed through a screen by a triage nurse
- 5.35pm – She is given a triage score of four – the second-least serious category – recommending treatment within 60 minutes. The family enter a waiting room
- 5.41pm – Prasitha expresses concerns about white spots on Aishwarya’s eyes. Junior doctor Tony Teo inspects the girl but does not make any notes. Dr Teo later testifies he didn’t have access to the triage notes and was unaware of her other symptoms.
- 5.51pm – Prasitha again seeks help. Registered nurse Tahnee Vining inspects Aishwarya, noting she has an elevated heart rate, respiratory rate and temperature of 38.8C and is grunting in pain. The nurse records family concern as “zero”. She does not consider sepsis despite being required to under hospital protocols. She is called away to help other patients.
- 6.43pm – Ms Vining completes a verbal handover with nurse Caitlin Wills, recommending pain relief and fluids.
- 7.00pm – Laying down on the waiting room couch, Aishwarya tells her parents she feels like she is falling. Her speech is increasingly faint.
- 7.05pm – Aishwarya is assessed by Ms Wills. She observes the girl to have a blank stare. She is floppy and unable to lift her arms or her neck.
- 7.09pm – ED consultant William Hollaway sees Aishwarya and moves her immediately to a treatment pod.
- 7.18pm – The rapidly deteriorating girl is moved by stretcher to a resuscitation area. She goes into cardiac arrest. Doctors try desperately to save her.
- 9.04pm – Aishwarya is pronounced dead. A post-mortem later identifies the cause of death as a sepsis infection related to group A streptococcus.
- Then-health minister Roger Cook requests an urgent briefing on the circumstances of Aishwarya’s death after her parents tell media their concerns were ignored by hospital staff.
- Cook apologises on behalf of the state government, saying Aishwarya should have received better care. He claims staff shortages did not contribute to the incident and fends off calls for his resignation.
- Healthcare unions express fury after junior staff at Perth Children’s Hospital are referred to the medical watchdog over Aishwarya’s death.
- Staff rally outside Perth Children’s Hospital, urging the government to act on safety and resourcing concerns.
- An independent report finds hospital staff were “exhausted and demoralised” and waiting areas “suboptimally staffed” in the lead-up to Aishwarya’s death.
- Perth Children’s Hospital boss Aresh Anwar resigns weeks before an inquest begins into Aishwarya’s death.
- Deputy State Coroner Sarah Linton concludes the inquest after hearing evidence from more than 20 witnesses.
- Linton finds there is a small chance Aishwarya’s life could have been saved. She finds staff missed the signs of sepsis because of pressures caused by “insufficient” staffing.
Source: www.9news.com.au
