This was published 1 year ago
‘Spend money on hospitals’: Coroner scathing of government resourcing after Aishwarya’s death
By Hamish Hastie
Seven-year-old Aishwarya Aswath died of natural causes but may still be alive had she received medical treatment at Perth Children’s Hospital sooner, Western Australia’s deputy coroner Sarah Linton has found.
“I am satisfied on the evidence before me that there was a small possibility that if proper treatment had been initiated between the time between when Aishwarya first presented to the hospital and after her observations were first taken ... that Aishwarya’s life might have been saved,” Linton said.
Aishwarya Aswath died after waiting hours for help at the hospital.
“That chance, albeit statistically small, was enormously significant to Aishwarya’s family.”
Linton found multiple staff missed key signs that should have resulted in an escalation of Aishwarya’s care but poor record-keeping systems and understaffing contributed to delays.
“Aishwarya’s parents brought their daughter in to hospital because they knew she needed help, but due to the pressures on them, the medical and nursing staff missed the signs that she was critically ill from sepsis and failed to rescue her. It really is as simple, and as tragic, as that.”
Linton made five recommendations to the state government, Child and Adolescent Health Service and Department of Health to improve staffing and resourcing in the health system including a recommendation to the state to expedite an existing commitment to legislate four-to-one nurse-to-patient ratios.
Coroner’s recommendations
- Department of Health/CAHS commit to early implementation of nurse/midwife-to-patient ratios in replacement of the current model in Western Australian public hospitals, as advocated for by the Australian Nursing Federation. This should be actioned without waiting for the Taskforce to complete its work or for any agreement with the ANF to be registered.
- CAHS prioritise the implementation and staffing of a specialist resuscitation team in the ED at PCH.
- WA Government consider the introduction of ‘safe harbour’ provisions to protect nurses from AHPRA investigation and prosecution when an adverse event occurs in the context of the nurse doing their work in circumstances where known risks in the workplace have been identified and not rectified by the employer.
- State Government prioritise funding the Department of Health’s EMR Program to ensure that as soon as practicable, all public hospitals in WA, and in particular PCH, have access to digital tools that make it easier for all staff to record information, access medical records and be supported in their clinical assessments.
- CAHS give consideration to implementing a new procedure for observations to be taken at triage or alternatively, within half an hour by the waiting room nurse, at PCH, when children present with gastrointestinal symptoms.
Her parents Aswath Chavittupara and Prasitha Sasidharan took Aishwarya to the emergency department in the afternoon, but she was categorised as a non-urgent patient and it took 90 minutes for her to progress from the waiting room despite a significant deterioration in her condition and her parents continually raising their concerns with staff.
Three-and-a-half hours after she arrived at the hospital she was pronounced dead.
‘Missed opportunities’
The nine-day inquest held in August and September investigated whether Aishwarya’s condition was beyond help or if earlier medical intervention could have saved her life.
The time it took for her treatment to begin was the impetus for Aishwarya’s parents to share their pain with the media just days after her death and the resulting backlash continues to be felt in the health system and at the highest levels politically.
“It shouldn’t take the death of a beloved little girl for the Department of Health and the government to stop and consider what more it can do ... to keep children safe.”
WA Deputy Coroner Sarah Linton
The coroner pinpointed three moments where medical staff missed signs that would have identified the sepsis earlier.
The first of those was when the PCH triage nurse at the time assessed Aishwarya as having a viral gastrointestinal illness, which was common for children presenting at the ED.
Aishwarya was triaged as a non-urgent category 4 patient despite her parents complaining of cool hands and gastro symptoms, which together Linton said could have led to a diagnosis of sepsis.
Linton said the design of the triage area, which had the nurse sat behind a perspex screen and two locked doors meant Aishwarya was not physically assessed, which may have prompted more concern from the hospital.
“The triage process was the first missed opportunity for anyone at PCH to realise that Aishwarya was seriously unwell and required urgent treatment,” she said.
The second missed opportunity was when a junior doctor working his first rotation as a pediatric trainee, assessed her in the waiting room.
Linton said that doctor was told to look at Aishwarya’s eyes, which were developing white patches, which he did but he did not perform any other assessment and did not touch her.
“[The doctor] could have taken steps to have Aishwarya’s treatment prioritised if he had realised that it was necessary,” she said.
“Unfortunately, he did not as he did not have a full picture of her presentation or the time to assess her fully, so he did not appreciate that she was critically unwell.”
Finally, the third missed opportunity was during another assessment by a junior nurse in the waiting room area when Aishwarya’s temperature was recorded at 38.8 degrees, but that was written on her arm and not registered in the correct system, known as PARROT, which would have alerted the hospital that she may be suffering from sepsis.
“The assessment by [the nurse] was the third, and arguably the most significant, missed opportunity for a PCH staff member to recognise that Aishwarya was seriously unwell and potentially septic.”
Linton found the type of sepsis that killed Aishwarya could be difficult to diagnose, particularly in children, and without early antibiotic treatment, it was often fatal.
Staffing was the biggest issue
The state government has maintained that the hospital was staffed correctly but medical staff working the night she died told the inquiry a different story.
Linton delivered a stinging rebuke to the government’s claims, placing much of the blame for the hospital’s woes on the government rather than individuals working on the night.
She said the evidence was that health bureaucrats were aware of significant staffing issues as well as the former Health Minister Roger Cook thanks to staff and Australian Nursing Federation raising the issue as soon as five days before Aishwarya’s death.
“Nurses and doctors are left with little choice but to work within the constraints of the working environment as it presents itself to them, while raising their concerns ... the background points to systemic issues surrounding the resourcing of the ED, rather than the behaviour of individuals in this case,” she said.
Linton noted the state’s efforts to pump more staffing into the hospital and its commitment to legislate staffing ratios of four patients to one nurse but said it should not have taken the death of a child to make these things happen.
“It shouldn’t take the death of a beloved little girl for the Department of Health, and the government, to stop and consider what more it can do, and how much more money it should spend, to keep children safe when they visit our specialist children’s hospital,” she said.
“We are fortunate as a state to have come out of the pandemic in a relatively healthy financial position, and while I acknowledge there are many competing demands on the public purse, the health of our community, and particularly our children, must be a priority.
“That means spending money on providing a positive practice environment for the nurses, doctors and support staff who run these hospitals and in particular PCH.
“There is no point in having a state-of-the-art facility, if the staff working within it are stretched beyond capacity and parents lose their trust and faith in them.”
Child and Adolescent Health Service chairwoman Debbie Karasinski stood down from her role in the aftermath of the incident and just weeks before the coronial inquest began in August 2022 CAHS boss Aresh Anwar also tendered his resignation.
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