Tara Cosoleto
An eight-year-old girl could have been saved if an emergency department doctor had realised the urgency of escalating her care to intensive care clinicians, a coroner has found.
Amrita Varshini Lanka’s parents nodded and wiped away tears as Victoria’s deputy state coroner Paresa Spanos handed down her findings on Wednesday.
Amrita died from lymphocytic myocarditis, or inflammation of the heart muscle, at Monash Children’s Hospital on April 30, 2022.
She had presented at the emergency department about 1pm on April 29, following two days of stomach pain, nausea and vomiting.
Testing quickly ruled out appendicitis, so hospital staff began working on the basis she had gastroenteritis.
Early the next morning, Amrita’s mother Satya Tarapureddi raised concerns with staff that her daughter was experiencing chest pain and a shortness of breath.
Amrita underwent an electrocardiogram (ECG) half an hour later at 3.30am, which came back abnormal and led the emergency department registrar Patrick Tan to suspect she had myocarditis.
He consulted with another colleague, who agreed with his preliminary diagnosis.
But neither doctor seemed to appreciate the severity of Amrita’s condition, the coroner said.
Amrita’s blood pressure was not measured at that time, but other testing showed elevated lactate, which signified that she was deteriorating.
Despite this, Tan determined that Amrita did not look unwell. He did not attend to the eight-year-old again until 5.30am, when it was clear her condition had worsened.
Her care was escalated to senior clinicians and specialist units, but she suffered a brief cardiac arrest at 7.30am.
Staff then organised emergency transfer to the Royal Children’s Hospital and a crew arrived about 8.51am, by which time Amrita had gone into prolonged cardiac arrest. Despite efforts at CPR, she could not be saved.
In a 2024 inquest into Amrita’s death, Monash Health admitted staff had failed to appreciate the seriousness of the girl’s condition.
The coroner heard when Tan began his shift 18 patients were under his care, and he was also responsible for any patients who presented to the ED after that.
Tan told the court at one point during his shift, when a critical test result came back for Amrita, he was dealing with a category 1 patient who had been brought in.
On Wednesday, Spanos determined Amrita’s death was preventable.
“When the ECG had been completed and the elevated lactate was available [at about 4am], Amrita’s life could have been saved,” the coroner said in her findings.
“While I accept that [emergency departments] are busy places and Dr Tan was a relatively junior doctor with many responsibilities, the clinical management and care he provided to Amrita was wanting,” the coroner said.
His actions, Spanos told the court, “thereby caused or contributed to her death”.
The coroner did not make any formal recommendations, instead commending Monash Health for undertaking an internal review following Amrita’s death.
Spanos acknowledged the hospital had implemented a series of changes as a result, including requiring emergency department clinicians to notify on-call consultants in specific cases.
The coroner, who at times appeared to hold back tears while reading her findings, offered her condolences to Amrita’s parents seated in the courtroom.
The couple did not speak to media as they left court.
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