The triage nurse who assigned seven-year-old Aishwarya Aswath a low priority score at Perth Children's Hospital says if she had more time and resources that may have changed the child's care.
Aishwarya died of sepsis after waiting almost two hours at the emergency department of Perth Children's Hospital for treatment in April last year.
A coronial inquest is investigating how trained professionals missed the warning signs and why her parents' concerns were not acted on at an earlier stage.
Her parents — mother Prasitha Sasidharan and father Aswath Chavittupara — on Thursday attended court with a large framed photo of Aishwarya, which they placed facing outwards on one of the courtroom chairs.
Hospital stress points
Triage nurse Jacqueline Taylor told the court staff had been under pressure last year when Aishwarya was carried through the emergency department doors.
"The whole department was running under a lot of pressure, time pressure and exhaustion and a long period of fatigue where we required more resources," Ms Taylor said.
"Being given the time to do a more thorough assessment could have changed the path of her care."
Ms Taylor gave evidence that on the night of April 3 last year, she assigned Aishwarya a triage assessment score of four – on the lower end of the scale of severity.
It meant when the family entered the waiting area, they were assigned to Pod C, and other patients in another section were prioritised.
Distressing footage shown
Aishwarya's parents briefly left the court when CCTV footage of the triage area was played, with her mother yesterday saying she couldn't bring herself to watch the CCTV of her daughter's final moments.
Nurse Taylor was quizzed on what signs she was looking for and why she formed the conclusion Aishwarya was suffering from a gastrointestinal issue.
She noted a history of diarrhoea and vomiting, but did not realise Aishwarya was wearing a diaper.
Nurse Taylor was asked whether Aishwarya's cold hands were indicative of something more serious, but she said many children presented with this symptom.
She said based on the information she was presented with at the time, she believed the triage score of 4 was appropriate.
She was not aware of Aishwarya experiencing pain over all of her body, and if she had known, it might have changed her assessment.
No hands-on assessment
The CCTV showed Ms Taylor spoke with the family but did not touch Aishwarya or perform a hands-on assessment, something she agreed was not optimal but was the standard practice at the time due to time constraints.
She said there was no equipment at the triage area to perform more rigorous assessments such as temperature and respiratory checks.
In addition, a large perspex screen was between her and the family, which had been installed as a COVID prevention and security measure for nurses.
The court heard the size of the triage desk had since changed, bringing the nurse closer to the patients.
While she was assessing Aishwarya, two other families arrived, as well as someone who wanted to be let into the waiting room.
Performing 'three jobs at once'
The court also heard she was responsible for letting patients in and out of the main waiting area and escorting high-priority patients in.
"(You're) really expected to perform three jobs at the same time, … triage nurse, concierge and an escort role," the family's lawyer Tim Hammond put to her, to which she agreed.
She told the court there was no specific triage policy for PCH at that time, but she expected to spend two to five minutes with patients.
Doctor only checked Aishwarya's eyes
The inquest also heard from the "most junior" doctor on duty that night who was asked to look at Aishwarya in Pod C.
Aishwarya's mother approached a clerk in Pod C and told her she was concerned about "white patches" in Aishwarya's eyes.
In a statement of evidence read to the court, that clerk — who has no medical training — said she thought this might be a sign of febrile convulsions.
She says she told Dr Tony Kuok Liang Teo of Ms Sasidharan's concerns and added her observation of possible febrile convulsions — essentially seizures that can occur in children — but Dr Teo only heard the concerns about Aishwarya's eyes.
Dr Teo stressed when he examined Aishwarya he noted two discoloured patches on her sclera but there was no sign of febrile convulsions.
CCTV showed Dr Teo spent only 20 seconds with the family and looked into Aishwarya's eyes as she lay with her head back on her father's lap.
The doctor told the court the ED was busier than usual that night and he did not stop to check the triage notes for Aishwarya before going to see her.
He said he was not aware of her parents' other concerns and reported symptoms.
He did not touch her and only examined her eyes, before forming the position she did not need urgent intervention and could have a more extensive eye examination later on.
Her parents yesterday gave evidence that he barely spoke to them and did not make eye contact.
Dr Teo said this was likely due to the pressure he was under to get back to other patients, and the need to move quickly due to staffing constraints after at least two doctors called in sick that night.
Symptoms taken together could indicate sepsis, doctor says
Mr Hammond put it to Dr Teo that at the time he examined Aishwarya she had an elevated temperature, cool peripheries, signs of tachycardia, a headache, lethargy or "floppiness", to which Dr Teo agreed when taken together could indicate the onset of sepsis.
However under questioning from his own lawyer, Dr Teo also acknowledged those symptoms could indicate a more common gastrointestinal isssue as well, and taken alone were common in children presenting to the ED.
But Dr Teo said if he had been aware of these symptoms and suspected sepsis in Aishwarya he would have brought her through to a higher priority area and commenced more thorough investigations, potentially including treatment with antibiotics and fluids.
Coroner Sarah Linton asked Dr Teo if he had "slowed down a little bit, spoken to the parents a little bit, it would have become apparent their concern wasn't just about their eyes?"
"Yes, with the benefit of hindsight," Dr Teo said, also acknowledging he regretted not taking more time that day.
Opportunity missed to recognise 'something more'
He agreed with the coroner's suggestion it was a "missed opportunity to recognise maybe there was something more going on with Aishwarya".
The coroner acknowledged Dr Teo had thought deeply about the events of that night.
In his evidence, Dr Teo suggested there could be benefits in establishing a rapid assessment team in triage comprised of a doctor and nurse, which he observed operating during a placement at Sir Charles Gairdner Hospital.
The inquest also heard from an administrative clerk who was working in the ED waiting area when the family arrived.
Aishwarya's mother approached clerks multiple times to raise concerns about Aishwarya deteriorating in the waiting room.
She gave evidence that clerks were not given specific training in how to refer patients up if they raised concerns, but said she relied on common sense.
