A girl who died in a busy emergency department at the age of just eight “could have been saved” with swifter intervention, a coroner has ruled.
Amrita Lanka died at Monash Medical Centre of lymphocytic myocarditis – a condition whereby the heart muscle becomes inflamed.
The day prior to her death, she was admitted to the southeast Melbourne hospital’s emergency department following two days of nausea, vomiting, diarrhoea and abdominal pain.
Her condition rapidly worsened and less than 24 hours after he admission, she died.
A coroner has found that signs she was deteriorating went missed by the junior doctor who was leading her care – adding her death could have been prevented.
In a report published this week, Paresa Spanos, deputy state coroner for Victoria, said overnight registrar Dr Patrick Tan did not appreciate the severity of her symptoms.
She was admitted to hospital and triaged shortly before 1pm on April 29, 2022, when she was alert and with vital signs within normal range, the coroner’s report states.
However, her symptoms continued throughout the day, with hospital staff carrying out a range of tests and a working diagnosis of gastroenteritis established.
As time passed, Amrita’s mother noticed her daughter was finding it tougher to breathe and suffering chest pains.
An electrocardiogram (ECG) was completed – at 3.30am the on April 30.
The examination established abnormalities, leading Dr Tam to suspect myocarditis. However, the girl was not immediately transferred to a pediatric intensive care unit.
“There is a consensus in the evidence that certainly by 4am, when the ECH had been completed and the elevated lactate was available, Amrita’s life could have been saved with timely escalation to PICU and pediatric cardiology,” Ms Spanos wrote.
“While I accept that EDs 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.”
Ms Spanos described a number of missed opportunities to escalate Amrita’s care in the face of her deteriorating health following her admission.
She said these included during a medical review at 6am when she gave low blood pressure readings and a handover between Dr Tan and another doctor which did not establish the severity of her condition.
She died at 10.46am having suffered a prolonged cardiac arrest.
HOSPITAL’S CHANGES
The coroner’s report states that Amrita’s death has been subject to a significant internal review by Monash Health to address “systemic issues” highlighted in her tragic case.
Among changes brought in were a new requirement for any emergency department clinician to inform an on call consultant of any child with the same lactate levels Amrita showed.
Changes have also been made to how ECG results are interpreted by ED staff.
“Amrita’s death was a tragedy, and our thoughts and deepest sympathies remain with her family and loved ones, a spokesman for Monash Health, which runs the facility, said in a statement.
“We acknowledge the coroner’s findings and will carefully consider them.
“Since Amrita’s death, Monash Health has made changes to strengthen patient monitoring, escalation of care and communication, and we remain committed to learning and improving patient safety.”
PRECIOUS DAUGHTER
In offering her condolences to Amrita’s family, the coroner described the child’s unbreakable bond with her parents and brother.
She lived in Clayton South, a Melbourne suburb about 20km southeast of the Victorian capital, with her father Chandra Lanka, her mother and her brother.
“In a coronial impact statement, Satya described her daughter as the most precious, talented, beautiful child who loved art and animals, especially birds,” the coroner wrote.
“Amrita played the piano, was very smart and was the centre of their universe.”
She added that Amrita was “greatly missed by all her family and the broader community”.