A damning review has uncovered multiple serious issues with the care of an eight-year-old girl who died in Monash Children's Hospital in April.
The sentinel event review was triggered following the death of Amrita Lanka. Her parents told the ABC at the time their repeated pleas for assistance went unheard.
A letter sent to Chandra Sekhar Lanka and Satya Tarapureddi from Monash Health outlining the review findings stated doctors misinterpreted Amrita's ECG results and "wrongly assumed" that her abnormal blood results were "falsely elevated".
"The staff did not follow a procedure which assesses parental level of concern every time vital signs are taken," the letter read.
Amrita's parents said they now live out "a lifetime punishment".
"We were sitting ducks there. We trusted them," Mr Lanka said.
"When you have a hospital where they ignore an abnormal ECG, they ignore an abnormal blood report, they ignored low [blood pressure], they ignored the pleas of Amrita herself, they ignored the pleas of her mother, that raises the question – why did we even go to the hospital?"
There was also a significant delay in organising the transfer of Amrita to the Royal Children's Hospital, where heart-replacement life support was available.
"There was a window between about 03:30 and 06:00 where Amrita could have been transferred to the Royal Children's Hospital for Extracorporeal Life Support," the letter stated.
"Early transfer may have improved her chance of survival, although panel members expressed reservations, given the severity of the changes on the ECG and her low blood pressure," it said.
Amrita's family has engaged with lawyers to investigate a medical negligence claim against Monash Children's Hospital.
"It appears from the medical records that there were deficiencies in Amrita's care, including a failure to adequately monitor her vital signs, or act on pathology results. There are crucial questions that still need to be investigated," a statement from Slater and Gordon read.
"Whether or not her death could have been prevented will form part of our investigation, along with any entitlement the family has to compensation."
Parents call for review of Amrita's entire time in hospital
Amrita's parents said the review failed to acknowledge the "valuable hours" leading up to their daughter becoming acutely ill.
Ms Tarapureddi struggled to get help for her daughter, pressing a staff assistance button multiple times before seeking out help at a reception desk.
Amrita died after her heart stopped about 21 hours after she went to hospital with stomach pains, which a GP initially thought may be appendicitis.
An autopsy later found she died as a result of myocarditis — inflammation of the heart muscle — presumed to be secondary to a viral illness.
Amrita's parents are calling for an independent external review to be undertaken looking at the entire period their daughter was admitted, in the hope it will prevent similar tragedies.
Ms Tarapureddi said it was "torture" knowing Amrita might have lived if her care had been better in the hospital's emergency department.
"Do you know how painful and unbearable [it is] when a child dies in front of us, the parents?" she asked.
"We are doubtful of the protocols in place in Monash Children's Hospital, are they really safeguarding a patient from dying?" Mr Lanka said.
"We want to appeal to the health minister, please positively respond to the external inquiry, send out a message to the Australian public that the government is serious to not let this happen again, and that the government is serious to find out all of the flaws in the [hospital's] care and to act on it."
On Thursday, the parents of 23-month-old Zayne Hassan-Cramer told the ABC about their concerns with the care he received at Monash Children's Hospital in the lead-up to his death last month.
Zayne's death is the latest in a spate of child deaths in Victorian hospitals which led to senior paediatricians last month calling for an investigation into the beleaguered health system.
Health service says changes will 'minimise the risk of such a tragedy recurring'
Amrita's parents have shared the letter they received about the review into her death on what would have been their daughter's ninth birthday.
"It used to be a wonderful day for us," Mr Lanka said through tears.
"Just like anyone else, we used to have a party at home. She would be very eager to open her gifts."
The review has put forward 11 recommendations, and Monash Health has confirmed it will implement each in full over the span of six months.
"We offer our sincere condolences and support to Amrita's family," a spokesperson said.
The recommendations include:
- Reviewing the current rostering to ensure there is an "optimal skill mix" among medical staff in the paediatric emergency department overnight
- Ensuring a consistent approach to monitoring vital signs in paediatric patients in the emergency department
- Clarifying the Monash Health referral process to specialised life support services at the Royal Children's Hospital
- Reviewing and improving processes around escalation of care for families and carers of acutely ill patients
Health Minister Mary-Anne Thomas said Safer Care Victoria had been undertaking its own independent review which was ongoing.
"It is my expectation that patients receive the best care possible – we established Safer Care Victoria to constantly review the safety and quality of care of patients and recommend any improvements needed across the public health system," she said.
"I want to pass on my thoughts and deep sympathy to the family of Amrita Lanka after this tragic event."
Premier Daniel Andrews said that there was still much work to be done in order to reform the system.
"This is not finished. There is more that has to be done and I give the family, and every family, my commitment, that the department, the hospital and Safer Care Victoria will work hard and implement any and all recommendations that can improve our system."
However, Mr Andrews did not make any commitments towards implementing a state-wide escalation protocol.
"I'd need advice from clinical experts about whether there's any further changes we could make," he said.
State-wide escalation protocols may be brought in
In other parts of the country, tragic deaths have resulted in statewide laws laying out a simple process for family members, carers or patients themselves to escalate their concerns.
In Queensland, the law is known as Ryan's Rule, after a toddler who died in Rockhampton in 2011, and in Western Australia it's called Aishwarya's CARE Call in honour of a nine-year-old who died in Perth in 2021.
Amrita's parents have suggested a similar law for Victoria to be dubbed Amrita's Rule to help make sure when people know their loved one is deteriorating, they can act.
"We understand that hospitals can make mistakes," Mr Lanka said.
"It's humans who are working at hospitals, so we can totally understand hospitals can make mistakes."
"You can make one mistake, you can make two mistakes, but you cannot have so many mistakes like in Amrita's case.
"We are fighting for the rights of parents and all caregivers so they know they can do something when no-one is hearing them."
The Department of Health said it was awaiting the outcome of Safer Care Victoria's investigation.
"Escalation protocols for parents, family and carers are tailored to each health service but if it were recommended by the experts that this be changed to a more uniform, system-wide approach, we would of course work with health services to achieve that," a health spokesperson said.
"If that review recommends any changes for escalation protocols, we will work to implement them immediately," said Health Minister Mary-Anne Thomas.
