A Melbourne health service admits to a series of oversights that left an eight-year-old girl dead after her mother said staff ignored desperate pleas for help.
Amrita Varshini Lanka died from lymphocytic myocarditis - inflammation of the heart muscle - at Monash Children's Hospital on April 30, 2022.
The girl presented at the emergency department with stomach pain and a fever.
Initial assessments ruled out appendicitis, with nurses instead believing Amrita had gastroenteritis.
But the child developed breathing issues before going into cardiac arrest a few hours later and could not be revived.
During an inquest on Monday, Satya Tarapureddi accused hospital staff of ignoring her pleas for help after her daughter began complaining of stomach pain.
When Amrita and her mum were taken to the hospital ward, about 3pm, a nurse showed her the emergency call button which she could press to get assistance.
Ms Tarapureddi said she pressed the button about seven times during the 21-hour ordeal, but no one came.
"Nobody was responding. They were ignoring me. I don't know the reason," she told the Melbourne Coroners Court on Monday.
She asked a hospital cleaner for help who confirmed the button was working.
Ms Tarapureddi said she approached the nurses' desk to tell them of her daughter's pain and the lack of response after pressing the button.
"The nurse told me I had to wait because they were having a conversation," she said.
A nurse arrived about 20 minutes later with Nurofen and then left.
Hours later, Amrita began experiencing difficulty breathing to which a doctor told her it was because she had not eaten anything.
In the early hours of April 30, Ms Tarapureddi expressed concern after seeing Amrita's pulse rate spike to more than 200 beats per minute.
But she said Patrick Tan, the emergency department registrar on that night, told her the machine was not working.
Amrita continued to complain of pain and an electrocardiogram to test the electrical signals in her heart was performed.
Amrita's mum said Dr Tan provided her the report and said it was "all good", despite him noticing there were abnormal results.
Hours later, Amrita's heart stopped for about two minutes before she was revived.
She died after experiencing a second cardiac arrest while waiting to be transferred to the Royal Children's Hospital.
"It's not easy to lose a daughter. It's very hard. They just ignored her," Ms Tarapureddi said.
"They lost my daughter. They killed my daughter."
Dr Tan gave evidence on Monday where he conceded there were oversights in Amrita's care.
He had 18 patients handed over to him that night, up from the usual 10, and said he did not appreciate the extent of the girl's condition, having attended to another category one patient.
Assessing Amrita's abnormal heart report, Dr Tan said he felt it was "reassuring and not a significant abnormality".
"At the time, in context of a significant clinical load, I did not recognise the interpretation," he said.
Dr Tan said it was a "difficult role to fulfil" that night having had little experience in emergency paediatrics.
He began his shift at midnight but he did not visit Amrita for three hours.
"I was not impressed upon that Amrita was an unwell child. The severity was not told to me. I don't recall being told of strange breathing," he said.
Lawyers for Monash Health admitted staff failed to appreciate the seriousness of the condition and Amrita's blood pressure should have been monitored more regularly and her condition escalated.
The inquest will investigate whether the care provided was reasonable, if the family's concerns were responded to adequately and if any resource constraints or competing demands contributed to her death.
Outside court, Amrita's parents hoped the inquest would provide answers to the "many questions we have about what went wrong ... and how it could have been prevented".
