Hospital ignored repeated pleas for help before eight-year-old’s death, court told

Satya Tarapureddi’s enduring memory of the day her daughter died is of frantically pressing an emergency buzzer next to a bed at the Monash Children’s Hospital as the child struggled to breathe and complained her chest hurt.

Tarapureddi estimated she pressed the buzzer for her eight-year-old, Amrita Lanka, at least seven times.

Amrita’s parents, Satya Tarapureddi and Chandra Sekhar Lanka, outside the Coroners’ Court on Monday.Credit: AAP

“She said: ‘Mummy, hard breathing, difficult to breathe,’” Tarapureddi told the Coroner’s Court on Monday. “I pressed the assistance button in our room, but nobody came.”

Tarapureddi said staff had instructed her to press the button if Amrita’s condition deteriorated.

“Just press the button. That’s the only one instruction given to me,” she told the court through tears. “There was no option for me. I am helpless. I am just waiting for some help.”

The mother told an inquest into her daughter’s 2022 death that her pleas to escalate her care over many hours were ignored by hospital staff.

“No doctor came ... I waited for more than 30 minutes,” she said. “I went to the nurses’ station and said Amrita was having difficult breathing. Nobody came. Each and every time I pressed the button, it happened, the same thing.”

Tarapureddi said that at one point, she became so concerned she thought the emergency buzzer might be broken and sought help from a nearby cleaner.

“She told me the button was working,” she said.

Amrita Lanka died in hospital aged eight.Credit: Justin McManus

Deputy State Coroner Paresa Spanos is examining whether the care Amrita received at Monash Children’s Hospital was reasonable and whether concerns raised by her family were appropriately responded to by staff.

Amrita was feverish, vomiting and had stomach pains when she arrived at the hospital at 1.30pm on April 29, 2022. Her father had taken her to a GP, who referred her to the hospital with suspected appendicitis.

After she had waited two hours in the emergency department, the hospital conducted an abdominal scan that ruled out appendicitis. The family was told she had gastro and she was given IV fluids.

But about 10pm, Tarapureddi said, she had pleaded with nurses and doctors for help when her daughter began to complain of chest pain and difficulty breathing.

Amrita died from lymphocytic myocarditis – inflammation of the heart – about 21 hours after she arrived at the hospital.

A review last year found several failings in Amrita’s care, including doctors not appreciating how severe her condition was until her heart stopped temporarily for the first time.

It also found hospital staff wrongly assumed Amrita’s blood results were falsely elevated and failed to monitor her falling blood pressure, an indication her heart was starting to fail.

Her family says that if her earlier tests had been interpreted correctly sooner, her case would have been escalated to the on-call cardiologist, potentially leading to faster diagnosis and treatment.

Dr Patrick Tan, the clinician in charge of the emergency department when Amrita died, told the inquest a handover he received at the start of his shift indicated she had suspected appendicitis and gastro symptoms.

Amrita’s family says that if tests had been interpreted correctly sooner, her case would have been escalated to an on-call cardiologist.Credit: Justin McManus

Tan said he became aware of more serious concerns for Amrita only when her mother told staff her daughter was deteriorating again at 3am.

“I recall that I was taken aback by this information,” he said.

“I had understood that Amrita was feeling better and wanted to go home.”

The inquest heard Tan was about three months into a rotation in the emergency paediatric unit at the time. He said he did not have a lot of experience in treating or diagnosing myocarditis.

He testified that it had been a busy shift with several patients requiring high levels of care, estimating he was responsible for overseeing care of about 18 patients.

At 3.30am, a nurse performed an electrocardiogram on Amrita to record the electrical signals in her heart.

Tan testified that while the results were abnormal, he did not recognise the severity of the abnormality. In hindsight, he said, the results of the ECG were “markedly abnormal”.

He said that when it become apparent Amrita had myocarditis, he felt a sense of urgency and anxiety.

“There was significant uncertainty on how to proceed,” he said.

Between 3.30am and 6am, Amrita was not attended to by any doctor, the inquest heard.

Tan was asked by lawyers representing Amrita’s family why he had taken more than 20 minutes to show the ECG results to the most senior emergency doctor there at the time.

He was also asked why he failed to escalate the case to a cardiologist and why there was a delay in checking Amrita’s blood pressure.

Tan said he sought advice from another doctor in the emergency department before taking the ECG results to a senior doctor.

At the beginning of the inquest, a statement from Monash Health, read out by barrister Fiona Ellis, admitted to failures in Amrita’s care.

“Monash Health expresses its genuine condolences to Amrita’s family on her passing,” Ellis told the court.

“Monash Health accepts there was a failure by it to appreciate the rapidly progressive nature of this condition and the need for timely treatment.

“It further accepts that Amrita’s blood pressure should have been monitored more frequently and that the results of her blood tests and investigations required that her care be quickly escalated.”

The inquest continues.

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