Videos: Doctors warned Vic gov emergency department child deaths were rising

Damning footage of doctors warning the state government mounting pressure on Vic’s buckling emergency departments has led to a spike in children dying has emerged.

Damning videos show top doctors alerted the state government in the lead-up to the 2022 election that serious emergency department failings were driving a rise in child deaths in hospitals.

The videos also reveal a significant review had been conducted into five years of child deaths and near misses – a fact the Andrews government did not disclose when questioned on the issue at the time.

That review found the number of children who died or suffered severe harm due to failings (called sentinel events) had “certainly” risen in emergency departments over the period.

Parents’ concerns were routinely ignored in sentinel event cases and there were issues with inadequate staff supervision, education and knowledge of resources that could be used for help, it also found.

Amrita Lanka died after Monash Children's Hospital missed signs she was seriously ill. Picture: Supplied

And the videos, capturing a series of virtual meetings held in late 2022 after several child hospital deaths last year, feature grave warnings from senior paediatricians.

Experts flagged a lack of “safe” waiting areas in overrun emergency departments as a key factor in children’s deterioration being unnoticed by staff.

There could be a bias against non-caucasian families, with child victims from diverse backgrounds “over-represented”, particularly those of Indian heritage, they noted.

The review – commissioned by the health department and agency Safer Care Victoria (SCV) – has still not been made public.

But an SCV annual report released last month acknowledged there had been a spike in pediatric sentinel events, which made up 38 of the 240 total incidents in the 2021-22 financial year.

The Andrews government then announced three reforms, including a virtual pediatrician network, to help smaller hospitals and plans for a statewide rule to allow parents to escalate their concerns.

One grieving parent yesterday slammed the government’s secrecy and lack of urgency on the issue.

Chandra Lanka’s eight-year-old daughter Amrita died from a rare heart inflammation condition after Monash Children’s Hospital missed signs she was critically ill.

“Why did they wait for so many children to die,” Mr Lanka said.

“We never had any sort of rights given to us to get the treatment that my daughter deserved.”

The videos, which are accessible on the SCV website, reveal pediatrician and SCV senior adviser Associate Professor Ed Oakley told a November meeting that half of all child sentinel events from the last five years had involved sepsis – a deadly but treatable condition if caught early.

Associate Professor Ed Oakley said half of all child sentinel events in the past five years involved sepsis.

It was not clear in most cases, but “a few times it was obvious and it just wasn’t recognised that the child was getting more unwell”, he said.

In addition to staff not hearing parents’ concerns – a key theme in “many” cases – there were “incidents of inadequate staff supervision, inadequate orientation” and “inadequate knowledge” of resources staff could have used for help, he said.

“Better education and more education for the staff, if you look back to the last 20 years, every sentinel event says that,” he said.

“Are we making a difference by doing that? No, we’re not.”

Doctors discussed a successful pilot program to encourage parents to speak up at six hospitals, whose practices they were “hoping” continued after funding ended, and other solutions in both the September and November meetings.

But Dr Bindu Bali said they also needed to acknowledge children of overseas heritage, “from particularly maybe Indian backgrounds”, had been “the predominant children” to die.

“Is the response to all families of all backgrounds equal?” she said.

The then Victorian Paediatric Network clinical lead Dr Annie Moulden said the review would look into this but “anecdotally you are absolutely right that there has been a very significant over representation of those children”.

Several doctors said high demand increased the risk by forcing more children into waiting rooms, where — depending on the hospital – kids “invisible” to staff could deteriorate, while others pointed to shortages of specialised nurses.

Emergency pediatrician Dr Adam West said waiting rooms “were a very difficult space to maintain safety” and demand was the “biggest elephant in the room”.

Dr West said when demand was high “there just simply isn’t enough room to find to put patients in areas that are safe” but their review had also shown sentinel events happened at less busy times as well.

Dr Annie Moulden. Picture: Supplied

“Despite everyone’s best efforts, despite all of our attempts, we continue to have children dying in our emergency departments,” she told the September meeting.

“There are also other events that are not sentinel events where there are outcomes that would not be acceptable for our children or our grandchildren.”

Dr David Krieser said it was “really, really difficult” to staff skilled pediatric nurses due to shortages.

“The difficulty we have had in convincing layers of administration, but then even individual nurses on the ground that a career in emergency pediatric nursing is viable, is quite incredible,” he said.

The Herald Sun first broke the news in September 2022 that doctors were concerned by at least seven child deaths in emergency departments that had happened since April that year.

At the time, SCV said the children’s deaths were being reviewed individually and they would need to wait until their data was finalised in 2023 to determine if there were any trends that needed action.

They did not publicly disclose the five-year review that was underway.

In response to questions about the videos from the Herald Sun, an Andrews Government spokesperson said: “Health systems around the world faced sustained and extraordinary demand during a one-in-100-year pandemic and we are continuing to invest to ensure all Victorians receive the very best care.

“Any death is a tragedy, particularly that of a child, and our thoughts are with the families who are suffering unthinkable grief.

“Health services review every sentinel event, listen to families and implement any recommendations in real time as part of the continuous improvement process.”

Daniel Andrews denied the government was told emergency department failings were driving a rise in child deaths. Picture: Jason Edwards

On Tuesday Premier Daniel Andrews said the government was not alerted by doctors that failings in the emergency department were driving a rise in child deaths.

“Not that I’m aware of,” he said.

“Safer Care Victoria is an independent body and works everyday.

“As part of a culture of open disclosure, we don’t want doctors and nurses and other people hiding things when they go wrong.

“They have to have the confidence to come forward to learn from every single error – whether that’s a sentinel event or an adverse event.

“Healthcare is very complex. It’s a high pressure environment. That sense of continuous environment only comes when you’ve got Safer Care Victoria working hard everyday to drive improvement from learning, and you’ve got a workforce that’s confident to come forward and be upfront about what’s happened or hasn’t happened.

“The death of any child is an unspeakable tragedy and this will be triggering and challenging for families who live with this every single day.”

But Mr Andrews rejected suggestions the government hid information about child deaths.

“No, not at all. That’s simply wrong,” he said.

Mr Andrews also shut down concerns made by the father of eight-year-old Amrita Lanka who died at Monash Hospital.

Chandra Lanka questioned why the government had waited for “so many children to die”.

Mr Andrews hit back at that claim, stating: “With the greatest of respect, that is not correct.”

“We make investments every single day and every year we’ve been in office, (make) profound investments, so I would, with the greatest of respect, reject that,” he said.

“I don’t think that’s a fair characterisation of what the government has done.”

Amrita Lanka’s tragic death

Amrita’s parents Chandra Sekhar Lanka and Satya Tarapureddi. Picture: Luis Enrique Ascui

A heartbroken father whose young daughter died after a hospital missed critical signs has questioned why the government waited “for so many children to die” before taking action.

Chandra Lanka and his wife Satya Tarapureddi have campaigned for change ever since their eight-year-old daughter Amrita Lanka died at Monash Children’s Hospital in April 2022.

A review into her death found an earlier transfer to Royal Children’s Hospital “may have improved her chances of survival” but Monash underestimated the severity of her illness and left it too late.

Mr Lanka said he was confident reforms to give parents a greater voice would help save other children, but wished it had not been too late for his kind-hearted daughter and so many other families.

Amrita Lanka with mum Satya Tarapureddi. Picture: Supplied

“Why did they wait for so many children to die,” he said.

“We never had any sort of rights given to us to get the treatment that my daughter deserved.”

Mr Lanka told the Herald Sun he was not surprised to learn families from diverse backgrounds were over-represented and his wife’s concerns were ignored.

He said he wanted the best for his children and he would not have moved them to Australia in 2016 if he had known how Amrita would be treated.

“I was so proud of Australian hospitals until this incident,” he said.

“That evening … I told her ‘look Amrita, you are in the best care’.

“Every child, irrespective of their race/gender/culture/religion, deserves to get the best care at Australian hospitals and that’s what hospitals are meant for.

“With the increase in sentinel events, it’s high time Government start addressing the systemic issues in healthcare, before it goes on to take more innocent lives.”

A Monash Health spokesman said they were “deeply saddened” by Amrita’s death and the recommendations of the review into her death would be implemented in full.