Call for change as parents grieve Amrita Lanka on what would have been her ninth birthday
An eight-year-old girl died at Monash Children’s Hospital after a litany of errors her family warns will see more children die.
Victoria
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A review into the death of an eight-year-old girl at a Melbourne hospital has uncovered a series of errors, as her grieving parents call for an overhaul of the system in her memory.
Amrita Lanka died at Monash Children’s Hospital on April 30 this year, a day after she was rushed to the emergency department.
On what would have been Amrita’s ninth birthday, parents Chandra Lanka and Satya Tarapureddi gathered at her grave to mourn their “beautiful”, “kind” daughter and call for urgent change in her honour.
In a letter sent to the parents by Monash Health, seen by the Herald Sun, the hospital acknowledged their Sentinel Event Review had identified errors including:
• Amrita’s abnormal ECG, first performed at 3.30am, was not interpreted correctly. While the doctor ordered blood tests, the review found they did not recognise “just how abnormal the (ECG) results were”. The on-call cardiologist was not contacted until three hours later, when blood tests confirmed Amrita had “significant” heart damage. The blood test results had been available for more than an hour, but the doctor had been treated “another critically unwell child”. The on-call cardiologist did not view the ECG, and was instead given information over the phone which meant they did “not appreciate the severity of Amerita’s cardiac condition”.
• “The seriousness of some of the abnormal blood results was not appreciated” and staff dismissed results indicating rising lactate as a “falsely elevated result, as Amrita appeared well”.
• There was an inadequate monitoring of vital signs.
• There was an earlier window where she “probably” could have been transferred to Royal Children’s Hospital for advanced care. Amrita was not referred for transfer until 7.45am.
The letter stated Amrita died of a rare heart inflammation condition called Lymphocytic Myocarditis, which they believe was triggered by a viral infection.
“Early transfer to the Royal Children’s Hospital may have improved her chances of survival, although the panel expressed reservations, given the severity of the changes on the ECG and her low blood pressure, which were indicative of the severity of the myocarditis,” the letter stated.
The family said their concerns Amrita’s condition was more serious than first thought were dismissed.
They are calling for Amrita’s Rule, a statewide escalation process for families who feel that their concerns about their loved ones are not being heard by hospital staff.
In a joint statement, her parents said they believe her death was preventable.
“We want Amrita’s Rule introduced in Victoria so that no other family’s concerns about their loved ones are ignored like we feel ours were,” they said.
“We believe that Amrita would still be alive if she had received better care at the hospital.
“While it’s reassuring that the hospital’s internal investigation confirms that Amrita did not receive the level of care she should have, the review far from addresses all of our concerns.”
Dad Chandra Lanka said they were speaking out to prevent other children from dying.
“Health Minister, the graves are filling fast,” he said.
“So please do act fast.
“The health system is broken.”
He said they should have spent Friday “celebrating her birthday with gifts and cakes”.
“But here we are mourning on her birthday,” he said.
“Every day is hell for us.
“Monash Hospital had sealed her fate.”
Mum Satya Tarapureddi said it was “torture”.
“How painful and unbearable for all the parents,” she said.
It comes after the Herald Sun revealed senior doctors were calling for a review of the state’s paediatric care following a recent spate of deaths.
Crucial questions still need to be investigated
The family is working with Slater and Gordon Practice Group Leader Lee Kimonides to investigate a medical negligence claim against the hospital.
Ms Kimonides said there were “crucial questions that still need to investigated”.
“It appears from the medical records that there were deficiencies in Amrita’s care, including a failure to adequately monitor her vital signs, or act on pathology results,” she said.
“The horror of Amrita’s deterioration unfolded before her parents’ eyes.
What happened to her is every parent’s worst nightmare, knowing your child is seriously ill while the hospital is brushing your concerns aside, culminating in the death of a bright and beautiful little girl.
“Whether or not her death could have been prevented will form part of our investigation, along with any entitlement the family has to compensation.”
A department of health spokesman said they would change escalation processes if experts recommend this.
“The death of any child is an absolute tragedy and our thoughts and deepest condolences are with the family of Amrita,” he said.
“As is standard practice when a patient dies in care, this incident was subject to a full clinical review, involving a number of external experts, and the investigation’s findings and recommendations have been shared with the family.
“Safer Care Victoria reviews every sentinel event to identify any potential emerging trends, so hospitals can then implement recommended improvements as quickly as possible.
“Escalation protocols for parents, family and carers are tailored to each health service but if it was recommended by the experts that this be changed to a more uniform, system-wide approach, we would of course work with health services to achieve that.”
A Monash Health spokesman said they were “deeply saddened” by Amrita’s death.
“We have met with Amrita’s family and shared the findings and recommendations of the review and investigation,” he said.
“This was undertaken by Monash Health involving external experts and in conjunction with Safer Care Victoria. Monash Health will implement each of the recommendations in full.
“We again offer our sincere condolences and support to Amrita’s family during this difficult time.”
Opposition pledges probe into child deaths
Opposition health spokeswoman Georgie Crozier said an elected Coalition government would immediately launch an independent investigation into a “string of child deaths” in Victorian hospitals.
“This is another heartbreaking case that demonstrates the true extent of Victoria’s health crisis,” she said.
“In July senior paediatricians sounded the warning and the Andrews government ignored their pleas.
“If elected a Guy government will immediately undertake an independent investigation into the string of child deaths that have occurred in our hospitals over the past few months.”
Premier offers commitment to Amrita’s family
Premier Daniel Andrews said he would need to seek advice from health experts before committing to a statewide escalation process in honour of Amrita.
“We already have a policy where we have different codes based on how much pressure is in the system,” he said on Friday.
“There are mechanisms in the system now to try and cope with any pressure that’s there at any given moment and particularly to make sure the most acute patients are treated quickest.
“I’d need advice from clinical experts about whether there’s any further changes that we can make.
“The commitment is to get that advice, to do that work and implement whatever improvements we possibly can.”
Asked if he supported the family’s plea for an independent review, Mr Andrews said the investigation was not yet over.
“This is not finished, there is more that has to be done, and I give the family and every family my commitment that the department, the hospital and Safer Care Victoria will work hard and will implement any and all recommendations that can improve our system,” he said.
“Let’s finish this work first, and then hopefully when we’re able to take the family and others through that work, we can have a discussion back and forth about what the next steps are beyond that.”
Mr Andrews said both Safer Care Victoria and Monash Health remained in contact with the Lanka family to provide them with the “support and information they are fundamentally entitled to”.
“Our sympathies are with that family. This will be an incredibly difficult and painful time for them,” he added.
“We send our love and support and best wishes to them at what is obviously a heartbreaking time.
“I send those messages not just as a Premier but as a parent. I can’t imagine just how difficult it will be for that family.”
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