A confidential report into the death of Aishwarya Aswath released by her parents reveals a “cascade of missed opportunities” to save the seven-year-old’s life.
Aishwarya died of sepsis on 3 April after contracting a bacterial infection related to group A streptococcus. Her desperate parents had begged to see a doctor at the emergency department of Perth Children's Hospital for nearly two hours.
A condensed version of the investigation report was released to the public last week. Aishwarya's parents subsequently released the full report as they continued to call for an independent inquiry into the tragedy.
"We didn't agree with what the findings were, we didn't agree with the timeline and therefore an external inquiry is going to be the only way that that will be resolved," family spokesperson Suresh Rajan said.
Her parents begged for medical attention. Source: Supplied: Suresh Rajan
Missed opportunities
The confidential report shows that Aishwarya was carried into the emergency department by her father at 5:32pm.
One minute later, Aishwarya’s mother told a triage nurse that her daughter had diarrhoea, had been vomiting and had cold hands as well as a headache.
No vital signs were taken at this stage and the nurse gave Aishwarya a triage score of 4, the second lowest priority, to be seen by a doctor within 60 minutes.
In the report, the panel determined the nurse did not take enough information to reliably decide the triage score.
“Specifically, there was not enough exploration of the parental concern of the cold peripheries; and the number of times the patient vomited and had diarrhoea,” the report read.
Several other hospital staff did not follow up the concerns of Aishwarya’s parents when they were raised.
In the 106 minutes between Aishwarya entering the emergency department and the start of resuscitation efforts, she was observed on CCTV to be "floppy", with her head "lolling back" while being "unable to lift her arms".
Her parents repeatedly walked over to staff and reported discolouration and "patches" appearing on Aishwarya’s eyes, but no further assessments were made.
“The mother and the father are watched to attempt to open (Aishwarya’s) eyes. Both appear agitated,” the report reads.
Aishwarya’s parents have previously described their desperate attempts to draw the attention of hospital staff to their daughter’s rapidly deteriorating condition.
Aishwarya's parents, Aswath Chavittupara and Prasitha Sasidharan. Source: SBS News/Aaron Fernandes
“We never saw any compassion from anyone. We found the staff were a bit rude, and we found the level of humanity they had was very low,” Ms Sasidharan has said.
The report notes five separate parental escalations to hospital staff that did not initiate a comprehensive assessment.
“The panel noted that the receiver of the escalated clinical information, whether it was an ED clerk to a nurse, or a nurse to a doctor, or a clerk to a doctor, never received or sought to explore the full clinical situation of the patient,” the report reads.
“The panel found there was a cascade of missed opportunities to address parental concerns and incomplete assessments, with a delay in escalation which may have contributed to the patient’s outcome.”
Observations made at 5:45pm show that Aishwarya was breathing rapidly and her heartbeat was racing.
Aishwarya’s vital signs were recorded at 5:52pm as a temperature of 38.8 degrees, respiratory rate of 44, heart rate of 150 and blood pressure of 114/103.
“Father states he is worried as patient is cold peripherally and has discoloured irises, on assessment patient is alert and clingy and grunting in pain…Mother anxious++”.
Despite the repeated and significant concerns for their daughter’s welfare, the report reveals that parental concern had been ticked as "absent" during the initial triage assessment, scoring a zero.
The nurse later explained to the review panel that “it was generally felt that every parent presenting to the emergency department was concerned about their child”.
Aishwarya’s condition deteriorated significantly as she reverted to speaking in Malayalam, the language from southern India spoken at home.
When Aishwarya’s perilous condition was recognised, she was taken to a resuscitation bay at 7:18pm.
An emergency consultant noted Aishwarya was already stiff in all four limbs and confused. The consultant formed a working diagnosis of encephalitis with possible seizures or sepsis.
At 7:25pm, Aishwarya’s temperature had risen to 39.8 degrees with a heart rate of 145.
Five minutes later, Aishwarya was no longer talking.
Source: Samuel Wiki / Public Domain
External inquiry
Following the parents’ decision to release the report, Child and Adolescent Health Service chief executive Aresh Anwar confirmed some staff involved in the clinical treatment of Aishwarya had been moved from their previous roles in the hospital.
“Those staff at the moment are not working in our emergency department,” Dr Anwar told reporters on Monday.
But he would not confirm where the staff had been moved to or how many staff involved in Aishwarya’s treatment were affected.
Fourteen staff directly involved with Aishwarya on 3 April and 11 staff indirectly involved were interviewed or provided statements to the review panel.
The review noted that a perceived lack of cultural awareness by staff for culturally and linguistically diverse (CALD) families and patients may have resulted in non-recognition of the family’s significant concerns whilst attempting to escalate care, which may have contributed to the delay in clinical intervention.
“The panel recognised the methodological limitations of the review, which meant they were unable to determine whether race or cultural background impacted on the care of the patient. The panel noted that institutional discrimination and racism towards people from culturally and linguistically diverse backgrounds and other specific population groups, who may be vulnerable within health systems should be further explored.”
After significant lobbying from her family, the Western Australian government has now committed to implementing an external review of the incident.
Both Mr Cook and Dr Anwar have faced calls to resign over the incident. Dr Anwar says he offered his resignation to the Director General of the WA Health Department, but it was rejected.
Western Australian Health Minister Roger Cook. Source: AAP
In refusing to stand down, Mr Cook has defended the actions and decisions of hospital staff, saying the public should not play ‘judge and jury’.
“Let the people who made those decision be given a chance to be heard in an appropriate forum”.
Dr Anwar says he agrees with the family’s criticism of how they were treated, but also did not want to hold individual clinicians responsible.
"I do agree with them when they say we showed them no compassion," he said.
“But blame is not the culture that we are trying to imbue through the organisation”.
