In short:
Monash Children's Hospital missed opportunities to save the life of a young girl in 2022, a coroner has found.
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coroner → miss → 2022
Amrita Lanka died from myocarditis less than 24 hours after being triaged, with a junior doctor telling the coroner's court he did not appreciate the severity of her condition.
What's next?
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What → die → condition
Monash Health says it will carefully consider the coroner's findings and is committed to improving patient safety.
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it → say → safety
The actions of a junior doctor working in a busy emergency department contributed to the death of a young girl whose life could have been saved, a Victorian coroner has found.
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coroner → work → girl
Amrita Lanka, eight, died from myocarditis in 2022 after arriving at the paediatric emergency department of Monash Medical Centre in Melbourne's south-east.
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Lanka → die → east
On Wednesday, Deputy State Coroner Paresa Spanos found Amrita's death was preventable and that the doctor in charge, Patrick Tan, did not appreciate the severity of the girl's symptoms in the early hours of April 30 that year.
"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 … and thereby caused or contributed to her death," Magistrate Spanos said.
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Spanos → find → death
She choked up and took a long pause as she described how Amrita was deeply missed, especially by her father Chandra Sekhar Lanka, mother Satya Tarapureddi and her brother.
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Amrita → choke → father
"Satya described her daughter as the most precious, talented and beautiful child who loved art and animals, especially birds.
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who → describe → art
Amrita played the piano, was very smart and was the centre of their universe," Magistrate Spanos said.
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Spanos → play → universe
The events leading up to Amrita's death
Amrita was referred to the emergency department on April 29, 2022 by her family doctor after two days of nausea, vomiting, diarrhoea and abdominal pain.
Magistrate Spanos said Amrita was alert and that her vital signs were in the normal range when she was triaged shortly before 1pm.
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she → lead → 1
Magistrate Spanos said doctors made a working diagnosis of gastroenteritis.
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doctors → say → gastroenteritis
The girl was placed in a cubicle that did not have an allocated nurse.
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that → place → nurse
Later that night, Amrita's mother said her daughter experienced "hard breathing".
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daughter → say → breathing
"She told me, 'Mama, hard breathing, hard breathing'.
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She → tell → me
Then immediately I pressed the staff assistance button but nobody came," Ms Tarapureddi told the ABC in 2022.
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Tarapureddi → press → 2022
"If they had put more attention to her, maybe today my Amrita could be sitting next to me."
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Amrita → put → me
The court heard that Dr Tan, the overnight registrar, conducted a review at about 3:20am on April 30.
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Tan → hear → April
An electrocardiogram test returned abnormal results, the court heard.
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court → return → results
Dr Tan suspected Amrita was suffering from myocarditis, but told the inquest he did not appreciate the severity of her condition.
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he → suspect → condition
Dr Tan, who was 12 weeks into his first paediatric rotation, said he was in charge of about 18 patients during his shift.
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he → say → shift
Further blood tests were ordered but no-one properly attended to Amrita until about 5:30am.
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one → order → 5:30am
A troponin test, which measures heart muscle damage, came back at more than 27,000 nanograms per litre.
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which → measure → litre
The normal level is below 10, the coroner said.
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coroner → say → 10
Amrita was transferred to the acute section of the emergency department and suffered three cardiac arrests, the last shortly after a retrieval team from the Royal Children's Hospital arrived.
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team → transfer → Hospital
Magistrate Spanos said Amrita was receiving a high level of care from Monash doctors by 8am on April 30.
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Amrita → say → April
But by then, she noted, "the die was already cast".
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die → note → ?
Life-saving opportunities missed, coroner finds
Magistrate Spanos said Amrita's life could have been saved with "timely escalation" and an earlier transfer to the RCH, which had specialised life support services for children with critical heart and lung conditions.
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which → save → conditions
Other missed opportunities for doctors included high lactate levels detected in a blood test and a low blood-pressure reading that should have triggered a medical emergency call.
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that → miss → call
Monash Health had made changes to practices and policies and improved staff education, the coroner said.
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coroner → make → education
Two other doctors involved in Amrita's care were cleared.
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doctors → involve → care
Monash Health conducted its own review in 2022 and admitted failings in the lead-up to Amrita's death.
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Health → conduct → death
At the time, Ms Tarapureddi said it was "torture" knowing Amrita might have lived if she received better care.
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she → say → care
"Do you know how painful and unbearable [it is] when a child dies in front of us, the parents?" she said.
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she → know → us
In a statement, Monash Health said it would carefully consider the coroner's findings.
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it → say → findings
"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," it said.
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it → make → safety
In 2024, the Victorian government trialled a telephone hotline for parents to ring if they believed their children were receiving inadequate care in hospital.
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children → trialle → hospital
The Kids Urgent Concern Helpline was expanded state-wide in July this year.
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Helpline → expand → July
The Aporia
