Child deaths at Victorian Victorian emergency departments sparks call for major statewide review

A spike in child deaths in Victoria’s emergency departments is “unsurprising” the state’s top doctor says, as he warned another child could die.

Questions have been raised about at least seven paediatric deaths since April.

Revelations over a spate of child deaths and near-misses in Victorian emergency departments are not surprising, one of the state’s peak medical bodies has warned.

It comes after the Herald Sun on Wednesday revealed a group of the state’s most senior paediatricians has demanded an urgent statewide review of the incidents, known as “sentinel events”, amid concerns more have been reported in the past six months than at any other time in Victoria’s history.

Australian Medical Association Victoria president Dr Roderick McRae said it was possible another child could lose their life, warning the healthcare system was still overwhelmed.

“This is as disappointing as it is unsurprising,” he said.

“If (there is) another sick child, there’s a lack of staff able to even hear from a concerned parent that they think their child is deteriorating, to monitor the child to actually get them in for resuscitation, and assessment and care.

“It’s clearly foreseeable that even one more such case could occur.”

He said the deaths were the price of living with Covid and pretending the pandemic was over.

“I’ve been quoted extensively recommending people heed the advice, the medical scientific advice about vaccination, mask wearing, physical distancing,” he said.

“This is the price that’s occurring, the emergency departments are overwhelmed.

“We’re aware of queues to get into the tent outside the emergency department.

“Staff are demoralised and leaving. And when senior people resign, a lot of expertise resigns with them.”

Victorian AMA president Dr Roderick McRae says the state’s healthcare system is still overwhelmed. Picture: Andrew Henshaw

Dr McRae said staff were trying their best, but when the system was so stretched, identifying a critically ill child in a queue stretching outside emergency department tents was like “identifying a needle in the haystack”.

“When a system is saturated, it cannot operate efficiently,” he said.

“(The AMA) have been quoted at length, explaining how overwhelmed the medical care system has been at every point.

“When people are in the car, in the car park (outside the emergency department), they’re not really observed.

“Sometimes there’s not a direct one person looking after a patient.”

He called for an investigation to collectively examine the deaths to see if there are “systemic issues” such as inadequate workforce or a lack of capacity.

“There appears to be some hesitation to establish a review,” he said.

“Is it satisfactory to wait until there are 10 episodes (deaths) or 20 episodes?

“If there is another underlying thing we want to know about it … as early as we possibly can.

“The brutal reality is … it may be as simple as the system was overwhelmed.”

While every case, including the death of 8-year-old Amrita Lanka, has been referred to Safer Care Victoria individually, a statewide review into Victoria’s paediatric emergency system has not been launched.

He said the issues in the healthcare system — from overwhelmed emergency departments to triple-zero delays — predate Covid and while he welcomed recent pre-election investment, more work was needed.

“It goes back 25 years,” he said.

“There’s been a failure to acknowledge the population has doubled, but the hospital capacity has not.

“There’s always a backlog of cases.”

Victorian Premier Daniel Andrews says Safer Care Victoria has been designed to review these events. Picture: Andrew Henshaw

Daniel Andrews defends handling of cases

It comes after Premier Daniel Andrews defended the government’s handling of the series of child deaths and near-misses in Victorian emergency departments, stating that Safer Care Victoria was already designed to review these events.

When asked about the reports, Mr Andrews said Safer Care Victoria, the peak authority for quality and safety in healthcare, reviewed “each and every sentinel event”.

“Of course we extend our deepest sympathies to anybody who’s lost a loved one during this pandemic event,” he said.

“That quality and safety framework is rigorous. It is the strongest in our country.

“There’s a whole agency now that wasn’t there many years ago (and) that’s obviously something that we have created.

“Some of the clinicians I know are involved in that work and they are 100 per cent committed to making sure that our hospitals learn from every adverse event, every sentinel event.”

There are calls for a major statewide review to prevent further tragedies.

Health Minister Mary-Anne Thomas said her thoughts were with the families involved.

“To lose a child in these circumstances is unimaginable,” she said.

“Safer Care Victoria’s focus is on safety and quality and ensuring that we have a culture of continuous improvement in our healthcare system.”

It comes after the Herald Sun has learned questions had been raised about at least seven paediatric deaths in emergency departments across the state since April.

Senior medical whistleblowers have sounded the alarm about the deaths and other near-misses calling for Safer Care Victoria to launch a major statewide review to prevent further tragedies, particularly in regional areas.

Senior paediatricians have told the Herald Sun that Victorian hospitals have reported more sentinel events involving children and babies in the past six months than at any other time in the state’s history.

Paediatricians flag concerns

While the circumstances of the individual deaths vary, a meeting of dozens of the state’s top paediatricians this month flagged growing concerns that an increase in serious adverse incidents may point to wider systemic issues that need to be immediately addressed, including severe cases of sepsis going undetected in children attending adult EDs.

Sepsis occurs when an infection gets in the bloodstream causing an extreme immune response in the body which can then lead to septic shock which causes organ dysfunction, heart failure and death.

It can also be revealed the directors of paediatrics from Victorian hospitals wrote to SCV in July warning it risked losing “visibility” of the paediatric sector by disbanding a network of specialists that monitored and responded to child safety issues within the hospital system.

The hospital safety watchdog this week refused to disclose how many paediatric sentinel event reports it had received this year, stating the data was still being finalised and would be released in 2023.

Senior medical whistleblowers have sounded the alarm about the deaths and other near misses.

SCV confirmed it was reviewing each case individually, but would await the finalisation of its data next year before determining if there were trends that warranted further action.

However, a senior paediatrician told the Herald Sun several hospitals feared their emergency department systems may not be adequately identifying children whose conditions are rapidly deteriorating in crowded waiting rooms.

“We have all these sentinel events occurring, yet who is looking at it?” the paediatrician said.

“The big issue is EDs and the identification of unwell children. These are mixed EDs where people don’t have the experience to identify these kids.”

A grieving family has also asked Victoria’s coroner and the Australian Health Practitioner Regulation Authority to examine the care their 20-month-old son received at Wangaratta hospital before his death.

It is understood Wangaratta emergency staff discharged the child on December 29, 2021, so his parents took him Benalla Hospital later that day only for him to be transferred back to Wangaratta as his condition deteriorated.

Overnight the baby began experiencing seizures and had to be intubated as an air ambulance was called to fly him to the RCH with meningitis, however he died the following day.

Sentinel events are the most serious adverse patient incidents that occur in the health system, resulting in death or serious harm due to safety issues.

There are fears emergency department systems may not be adequately identifying children whose conditions are rapidly deteriorating.

An SCV spokesman said the agency worked closely with health services to review every sentinel event and identify any potential emerging trends so improvements could be implemented quickly.

It also recently advised hospitals of issues relating to sepsis after concerns were raised about a number of paediatric cases presenting to the emergency departments.

“We’re building a strong reporting culture among hospital staff to learn from sentinel events and avoid tragic outcomes for more families in the future – working with health services to increase the reporting of these incidents every year,” the SCV spokesman said.

Of the 168 sentinel events reported to SCV in 2020-21, 20 involved paediatric patients – including 13 infants less than a week old, four babies under one year, and three children aged 6-18.

Detailed SCV reviews of last year’s horror cases identified 520 ‘root causes’ contributing to the adverse outcomes, resulting in 1041 recommendations to improve systems for future patients.

But senior paediatricians have told the Herald Sun they fear similar lessons will be missed if the health watchdog fails to fully investigate the surge in children's’ emergency department deaths.

Senior paediatricians are hopeful the health watchdog will investigate. Picture: Tim Carrafa

Their concerns come after an SCV restructure this year saw the dissolution of the Victorian Paediatric Clinical Network. The VPCN had operated since 2009 to examine safety issues and implement system-wide improvements across the state’s paediatric units and report to the watchdog.

In a confidential letter signed by the Victorian Directors of Paediatrics and sent to SCV chief executive officer Professor Mike Roberts on July 20, the state’s top regional and metropolitan children’s medical specialists “strongly request” the network continue its role.

“The phrase, ‘if it ain’t broke, don’t fix it’, does not give the VPCN the recognition it deserves. Not only is it not broken, but it has also been an extremely practical and effective instrument for achieving uniformity of paediatric care within a quality and safety framework,” the letter said.

After being contacted about allegations of a paediatric death in Rosebud hospital’s emergency department Peninsula Health confirmed it had referred a case o SCV for investigation, but could not provide further details.

“Our thoughts and deepest sympathies are with the family. Due to privacy and confidentiality, we are unable to comment further.”

An Epworth HealthCare spokesman said individual cases could not be commented on, but the service had a longstanding processes for reviewing clinical incidents that complied with all regulations.

“Our aim is to ensure we actively address any concerns from patients and their families in any review. All processes include collaboration with Safer Care Victoria and other agencies,” he said.

Barwon Health said it was unable to comment about the July 4 death of a one-year-old in the University Hospital Geelong emergency department while it awaited a coroner’s final report.

“Barwon Health has been liaising with the child’s family while a review into the death

has taken place with external experts,” Barwon Health said.

A Northern Health spokesman confirmed the July 12 death had been referred to Safer Care Victoria and the coroner for further investigation, and they were not able to comment further.

Northeast Wangaratta Health spokesman confirmed it has also referred a matter to SCV for further investigation as well as launching a multiagency review.

“The loss of any child is a tragedy and our condolences are with the family during this difficult time. We’re unable to make any further comment,” the Northeast Wangaratta Health spokesman said.

Eastern Health, which operates Angliss Hospital, said it would not comment on individual cases.