The outcomes of the inquest into the death of seven-year-old Aishwarya Aswath on 3 April 2021 have been released and the State Government is reeling.
The findings were delivered on 22 February 2023 by Deputy State Coroner Sarah Linton, who found that her death occurred by way of natural causes, with extensive post-mortem investigations showing that Aishwarya died from multiorgan failure caused by fulminant sepsis that developed due to a bacterial infection of Streptococcus pyogenes.
Based on evidence by experts, the Deputy State Coroner also found there was a small possibility that Aishwarya’s death might have been prevented if she had been given urgent medical treatment shortly after she first arrived at PCH.
“Aishwarya’s parents brought their daughter in to hospital because they knew she needed help,” Dr Linton said.
“But due to the pressures on them, the medical and nursing staff missed the signs that she was critically ill from sepsis and failed to rescue her. It really is as simple, and as tragic, as that.”
Dr Linton noted that fulminant sepsis can be difficult to diagnose, particularly in children, and without early antibiotic treatment it is often fatal, but pointed out that there were multiple opportunities where ED staff could have escalated her care.
The inquest, which ran from 24 August to 2 September 2022, not only investigated whether Aishwarya’s death was preventable, but also considered the underlying issues that contributed to the tragedy from a public health perspective, considering the results and recommendations of a Root Cause Analysis (SAC1) and an independent inquiry that had already been conducted.
The inquest made five recommendations for improvement to ensure that another tragedy such as Aishwarya’s does not occur again:
- Recommendation 1 – The Department of Health/CAHS should commit to the early implementation of nurse/midwife-to-patient ratios in replacement of the current NHpPD model in WA public hospitals, as advocated for by the ANF.
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- Focus should be given to ensuring a minimum ratio is put in place in EDs as a matter of priority, given the known risks to patient safety from missed care in this setting.
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- This should be actioned without waiting for the Taskforce to complete its work or for any agreement with the ANF to be registered. Patient safety should not wait for the outcome of such negotiations when the Department of Health’s own Independent Inquiry supports such a change. The standard can be set by reference to what is currently in place in Victoria.
- Recommendation 2 – That CAHS prioritise the implementation and staffing of a supernumerary resuscitation team in the ED at PCH.
- Recommendation 3 – The WA government should consider the introduction of ‘safe harbour’ provisions to protect nurses from Ahpra investigation and prosecution when an adverse event occurs in the context of the nurse doing their work in circumstances where known risks in the workplace have been identified and not rectified by the employer.
- Recommendation 4 – The WA government should prioritise funding the DOH’s EMR Program to ensure that as soon as practicable, all public hospitals in WA, and in particular PCH, have access to digital tools that make it easier for all staff to record information, access medical records and be supported in their clinical assessments.
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- This will significantly enhance patient safety in public hospitals.
- Recommendation 5 – That CAHS consider implementing a new procedure for observations to be taken at triage or alternatively, within half an hour by the waiting room nurse, at PCH, when children present with gastrointestinal symptoms.
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- This will ensure there is an early benchmark to measure the child’s progress and monitor for signs of sepsis.
“It shouldn’t take the death of a beloved little girl for the government to stop and consider what more it can do, and how much more money it should spend, to keep children safe when they visit our specialist children’s hospital,” Dr Linton said.
“There is no point in having a state-of-the-art facility, if the staff working within it are stretched beyond capacity and parents lose their trust and faith in them.”
The establishment of the supernumerary resuscitation team was something that WA Health minister, Ms Amber-Jade Sanderson, had initially claimed was already implemented at PCH, but it later emerged that the incorrect information had been supplied to the department by staff at the hospital.
The blame game between Minister Sanderson and Child and Adolescent Health Services chair, Ms Rosanna Capolingua, who passed this information on to the Minister, and the ANF, who asserted that this issue (among others) had still not been resolved, forced Minister Sanderson to admit that rostered ED staff were still being drawn away from their duties to perform resuscitations.
“The government has provided funding for that team, and I expected it to be in place,” she said.
Premier Mark McGowan defended the government’s position noting that when advice is provided to a department, the expectation is that it is correct.
The Premier was also drawn into discussions on the request by Aishwarya’s parents for a $5 million ex gratia payment that would go towards a foundation named in Aishwarya’s honour, admitting in an interview with ABC Radio Perth on 28 February 2023, that the family had already received money from the government.
“We’ve already been supporting the family financially, so that’s something that’s already occurred,” he said.
“We’ll examine what more we can do, but that’s something that’s already happened.
“I won’t go into exact details … obviously it’s a very sensitive matter and it’s a tragic situation, and they’re a family that have been through a lot of grief and pain, so we provided some support, I think it was last year.
“You don’t always make these things public. It is a very personal matter… It is a family that lost a child and going through a lot of pain and suffering and a lot of grief.”
Mr McGowan urged ‘sensitivity’ when asked for more detail about the payment.
“There’s a family that lost a child,” Mr McGowan said.
“I would just urge you to be a little bit sensitive about these matters, and obviously you saw their grief and you read about their grief in the coroner’s inquiry report.”
Aishwarya’s mother, Mrs Sasidharan Chavittupara, urged the WA government to act on Dr Linton’s recommendations immediately.
“Every mother should be cherishing their children’s achievements and sharing their children’s happiness, but I am holding my daughter’s death certificate and inquest report,” she said.
“I’m just asking the authorities please implement those recommendations if they think that will help and please make sure another mother (does not) have to go through the same thing.”