It's a parent's nightmare — the unexplained death of a child in an environment where they should have the best possible care: a hospital.
It's exactly what happened to the family of young girl Amrita Lanka, who died in Melbourne last month.
The eight-year-old was brought to Monash Children's Hospital with stomach pains on April 29, where her parents were told Amrita's complaints of breathing difficulty were caused by an empty stomach.
By the time doctors had realised how sick Amrita was, several hours later, it was too late.
The Australian Patients Association (APA) says it receives countless reports of similar situations from across the country.
It's calling for a national framework to provide independent reviews of such cases and says "stretched and struggling" public hospitals need more funding.
"There's no doubt that what happened at Monash Hospital could happen to any family," APA chief executive Stephen Mason said.
If you're worried about the treatment someone in hospital is receiving, how you escalate your concerns depends on where you live.
What is the situation in NSW?
In November, State Coroner Derek Lee found the death of a three-year-old girl at Sydney's Westmead children's hospital came after a string of "missed opportunities" to save her life.
Caitlin Cruz died from influenza B in October 2016 after being rushed to the hospital having collapsed and suffered a seizure at her local GP.
Despite this, reports of those critical symptoms were lost along the road from the clinic to Westmead when paramedics miscategorised clear signs of serious illness as "lethargy".
Caitlin had in fact developed fluid on her heart but didn't receive an ECG for four hours because the machine was out of battery.
Last year, her grieving mother stood outside the Lidcombe Coroner's Court to say Caitlin would still be alive if someone had "just cared enough that day".
The REACH program — Recognise, Engage, Act, Call, Help — was introduced across NSW hospitals in 2014 to assist patients and family to escalate their care status.
It provides a step-by-step guide to requesting clinical reviews of care which includes the ability to call a dedicated number to trigger an independent review or "rapid response" if concerns aren't resolved.
NSW Health's Acting Chief Executive Dr James Mackie said it was families who often noticed changes to their loved one's condition.
"REACH is about having a safety net for patients, families and carers," he said.
"REACH is widely available across NSW hospitals to patients in a variety of settings including emergency departments, mental health, adult and paediatric wards," he said.
However, Mr Mason said despite NSW being the most-populous state in the country, its system to escalate urgent situations was far from the benchmark.
How do other states compare?
Mr Mason said Queensland's escalation process was the "gold standard" in Australia, with Western Australia coming in second.
Both states have robust escalation policies — Ryan's Rule and Aishwarya's CARE Call respectively — which were introduced after the tragic deaths of children.
The rules allow patients, parents and family members to call for reviews if they feel their concerns aren't being listened to.
In Victoria, there is no blanket system for all hospitals.
While an escalation pilot program was launched in 2019 by Safer Care Victoria called HEAR Me, patient escalation is still determined by individual hospital policy.
Tasmania has a three-step patient safety protocol— the Call and Respond Early (CARE Call) protocol— in place for patients, family members and carers to raise concerns, including a dedicated phone number as a "final point of escalation".
The ACT has the Call and Respond Early (CARE) for Patient Safety Program where a patient themselves, family member or carer can go through a three step process with the final option being a phone call to a dedicated line for a senior nurse to assess their condition and assist as required.
In South Australia their Escalation of Care policy states a treating doctor must arrange for the patient to speak directly with a senior clinician if they are experiencing ongoing concerns about their condition or standard of care.
For the Top End, East Arnhem and the Big Rivers region, a system called REACT is in place encouraging concerned individuals to raise issues with a staff member or an Aboriginal Liaison Officer and only call a hotline (1800 290 888) if there is no change.
A "similar" system is in place in the Central Australia and Barkly regions.
Mr Mason said parents across the country have told the APA of their frustrations that "no one seems to take them seriously".
"Fortunately, there are not many deaths but no parent should be put in a situation where they don't know if their child is going to live or die, and no one seems to give a damn," he said.
Does anything need to change?
Mr Mason says the pressure hospital staff have been under during the COVID-19 pandemic might have exacerbated existing shortfalls in the health system.
Nurses are overworked and specialists are quitting their jobs, but Mr Mason said that wasn't an excuse for serious illnesses being missed.
The situation can be even worse in regional and rural areas of the nation, where staffing levels, resources, equipment and experience often pales in comparison to metro hospitals.
"It's not broken, but it's struggling a bit [the nation's health system]," he said.
"There's no doubt the hospital system needs more funding."
Mr Mason said introducing a national standard for escalation procedures was crucial to ensuring patients' safety, as was taking the reviews of failures such as the one that claimed Amrita's life out of the hands of the hospitals themselves.
"All these investigations have to be independent."
