Sentinel events Victoria: Safer Care report reveals child healthcare harm

The Andrews government says it will introduce new reforms after a sharp spike in the number of deaths and cases of serious harm among kids and young Victorians due to healthcare failures.

A report has revealed the number of sentinel events involving children has risen.

The number of children and young Victorians who died or experienced serious harm because of healthcare failures has skyrocketed, a new report has identified.

Safer Care Victoria’s annual Sentinel Events Report has revealed that the total number of events in 2021-22 had risen to 240, up from 168 the previous year.

Of those recent cases, 38 were children.

The government was unable to say how many of those 38 cases resulted in death.

A sentinel event happens when something goes wrong with a patient’s care, across both the public and private healthcare system, which causes the person serious harm or death that could have been prevented.

The parents of eight-year-old Amrita Lanka who died at Monash Children’s Hospital in April last year, said an escalation system would both honour their daughter’s life and ensure no other child faced the same fate.

Mr Lanka and Ms Tarapureddi have been lobbying the Health Minister and Safer Care Victoria for the escalation system to be named “Amrita’s Rule”.

A Sentinel Event Review into Amrita’s death uncovered a series of errors, which prompted her grieving parents, Chandra Lanka and Satya Tarapureddi, to fight everyday for reform.

The hospital acknowledged that their review had identified errors in the care provided to Amrita, and that she died of a rare heart inflammation condition called Lymphocytic Myocarditis.

Victorian Health Minister Mary-Anne Thomas apologises to families. Picture: Andrew Henshaw

On Monday, Mr Lanka and Ms Tarapureddi fought back tears as they remembered their daughters’ final pleas for help falling on deaf ears.

Mr Lanka recalled his wife desperately pleading with everyone in the hospital, “including the cleaner” to get help for their daughter.

“That night, no one had the heart to listen to Amrita’s pleas,” he said.

“We could not get any help.”

Ms Trapureddi said her repeated concerns were not listened to at the time.

“As a parent, I knew that something was going on with my daughter Amrita,” Ms Trapureddi said.

“I was told only to just press the button if you need any help. I was pressing the button and waiting ... I just kept requesting them to come and have a look at Amrita but I did not get any help from them.”

The grieving parents welcomed the government’s commitment to launch a statewide escalation system, but said it needs to be urgently implemented.

“If there was already a proper escalation system when Amrita was admitted to the hospital, today Amrita would have lived,” Ms Trapureddi said.

This year’s report highlighted an increase in cases related to children and young people.

It also revealed deterioration was the most significant factor contributing to paediatric sentinel events.

Health Minister Mary-Anne Thomas on Monday issued an apology to the families who lost a loved one because of a sentinel event.

“This is not OK. I’m sorry,” Ms Thomas said.

“Every sentinel event is a tragedy. We will learn from each and every event to honour the children affected, and to ensure that it does not happen again.”

In response the state government will unveil a series of reforms, including a new escalation system.

The new escalation system, which is already in place in other states, will give parents and carers an alternative pathway to raise concerns if they feel they are not being listened to.

A virtual paediatric consultation system will also be introduced, which will provide 24-hour access to specialist paediatric experts and services.

And the use of standardised and age-specific charts, known as the Victorian Children’s Tool for Observation and Response (ViCTOR), will be mandated.