Seven-year-old Aishwarya Aswath would have had a better chance of survival if she had received earlier treatment at Perth Children's Hospital, but her infection was so advanced it still would have been low, an infectious diseases expert has told an inquest into her death.
Aishwarya died following an almost two-hour wait for treatment at the hospital, after presenting with symptoms consistent with sepsis.
An inquest into her death is exploring why medical staff didn't realise the severity of her disease earlier and why her parents' pleas for help were not acted upon.
Infectious diseases expert David Speers told the inquest Aishwarya was facing a "perfect storm", with very high bacterial levels in her blood and toxic shock syndrome from that infection.
He gave evidence Aishwarya's illness was made worse by the type of bacterial infection – Streptococcus A – which typically results in a more rapid deterioration due to increased inflammatory response to the toxins it produces.
"These two factors made it less likely for Aishwarya to survive," he said.
'Rare and terrible' disease
"I would have thought that only a minority of children would have survived.
"This was an extremely rare severe disease process … this is a rare and terrible disease that progresses in this way."
Aishwarya entered the hospital at 5:35pm, was triaged with a low priority score and then assessed by a waiting room nurse at about 5:50pm.
That nurse did not complete her assessment after being called away to another urgent case, and Aishwarya was left languishing in the waiting room until about 7:15pm.
She did not receive the recommended treatment for sepsis – antibiotics — until after 7:30pm when she was taken into the resuscitation area of the ED.
Dr Speers was quizzed by the family's lawyer, Tim Hammond, on whether an earlier application of antibiotics and IV fluids could have saved Aishwarya's life.
Mortality rate very high
Referring to Dr Speers' report, Mr Hammond put to him: "You say (there is an) increase in risk of death in every hour … for every hour there is a delay?"
Dr Speers agreed.
But he said the mortality rate for severe toxic shock syndrome was very high.
And he gave evidence that once the toxic shock syndrome had occurred, even if antibiotics began to kill off the bacteria, an "inflammatory cascade" which attacked internal organs could still kill the patient.
He was asked by Mr Hammond whether Aishwarya's readings at the initial assessment in the waiting room — including a normal blood pressure reading — indicated she had not progressed to toxic shock syndrome at that point.
The doctor gave evidence children compensate well for bacterial infection and blood pressure was usually the last system to give, which could explain that reading.
He gave an example that blood can be pulled from peripheries such as hands and feet in order to keep organs supplied with oxygen – something that would be consistent with her symptoms of cool hands at the time she arrived at hospital.
"I think she had a lot of compensatory mechanisms in place," he said.
Severe toxic shock
He said given the limited investigation done in the waiting room it was not possible to say for certain how sick Aishwarya was at that point.
However, he agreed with Mr Hammond's assertion that the constellation of symptoms Aishwarya presented with in the waiting room would usually trigger escalation of care for suspected sepsis.
A blood test at 7:30pm once she was in the resuscitation area showed extremely elevated levels of acid in her blood, indicating a very severe case of toxic shock at that point.
Dr Speers said the only way to identify more cases of sepsis earlier was to trigger a sepsis "care pathway" – which would mean many children who did not have the infection would begin treatment.
However the inquest has heard earlier evidence that the broad application of antibiotics can result in a rise in antibiotic-resistant disease.
Triage area not 'fit for purpose'
Meanwhile, expert witness paediatrician Dr Sathiaseelan Nair told the inquest the PCH triage area was not fit for purpose.
He said it was difficult to diagnose sepsis but it was made even more challenging due to the layout.
"I truly believe had they had better staffing, a better triage that was fit for purpose, I certainly think things may have followed a different trajectory," he said.
Dr Nair said the staff were under too much pressure but it was "not only a problem of having the right number of staff, but having the right skills … experienced people".
"You get to the point where people are exhausted … we have to protect staff from getting to that point," he said.
He also said parental concern was an important consideration for any doctor, and that parents were usually the best source of information about their child.
