Health chief admits errors in WA girl’s death

The doctor in charge of WA’s child health service has said he cannot explain the string of mistakes that contributed to the death of a seven-year-old girl at Perth Children’s Hospital.

WA Health Minister Roger Cook. Picture: Colin Murty

The doctor in charge of Western Australia’s child health service has said he cannot explain the string of mistakes that contributed to the death of a seven-year-old girl at Perth Children’s Hospital.

He also said hospital staff had failed to show appropriate compassion and care as the girl’s condition worsened.

The full “root cause analysis” report into the death of Aish­warya Aswath after hospital staff failed to act despite repeated pleas from her parents for urgent medical attention was publicly released on Monday with the consent of the girl’s mother and father.

The report explains in detail how Aishwarya’s parents on five occasions sought attention from the emergency department clerk and clinical staff as their daughter’s health grew rapidly worse.

The family arrived at the hospital at 5.32pm on April 3, and by 5.45pm her father alerted staff that Aishwarya’s hands had gone cold and she was having problems with her eyes. At 5.52pm the girl was observed as “clingy” and “grunting in pain”, while her mother was pacing anxiously.

Aishwarya was still waiting to see a doctor when the first nurse who had examined her handed over to a second nurse at 6.45pm with a plan to give her ibuprofen.

It was not until 7.09pm that Aishwarya was seen by an emergency department doctor, who noted her “cold peripheries and slurred speech”.

Within 10 minutes, Aishwarya — who by now appeared “catatonic” — was rushed to a resuscitation bay where a frantic effort began to save her life. Less than two hours later, she was dead.

“There were a cascade of missed opportunities to address the parental concerns and incomplete assessments, with a delay in escalation, which may have contributed to the patient’s outcome,” the report finds.

Dr Aresh Anwar, the chief executive of the Child and Adolescent Health Service, said he could not explain why — despite the repeated pleas from Aishwarya’s parents for help — their concern was scored as “zero” when documented at the time.

He also said he was unable to explain why Aishwarya’s abnormal medical readings did not prompt earlier action.

“I agree with (Aishwarya’s parents) when they say we didn’t show them compassion. I agree with them that we didn’t appear to demonstrate care. And I agree with them (that) we didn’t interpret the signs correctly,” he said.

He confirmed that the staff ­involved in the incident were not working in the emergency department “at the moment”.

An independent inquiry and a coronial inquest will also be held into Aishwarya’s death, although WA Health Minister Roger Cook urged for the public not be the “judge and jury”.

“I know this report is raw, it is incredibly distressing, it is unbearably hard to read and it raises more questions than it answers,” Mr Cook said. “But can I please urge a level of caution as the next stage of inquiries take place.”

Aishwarya’s death has added to scrutiny over staffing levels and bed availability in WA’s health system. Ambulance ramping levels have touched record highs this year, and there have long been calls by health professionals for additional staff and improved procedures in the state’s hospitals.

Opposition health spokeswoman Libby Mettam said Aishwarya’s death was “a monu­mental failure” of the system.

“There were gaping holes in the staffing arrangements that evening, particularly in relation to the skill mix … and for the minister to suggest otherwise is simply ­untrue and an insult,” she said.