An eight-year-old girl’s death was preventable, a coroner has found as she criticised a Melbourne emergency department doctor’s response.
asserted
she → find → response
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.
asserted
Amrita → nod → April
She had presented at the emergency department about 1pm on April 29, following two days of stomach pain, nausea and vomiting.
asserted
She → present → pain
Testing quickly ruled out appendicitis, so hospital staff began working on the basis she had gastroenteritis.
asserted
she → rule → 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.
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daughter → raise → 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.
asserted
she → undergo → 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.
asserted
coroner → consult → condition
Amrita’s blood pressure was not measured at that time, but other testing showed elevated lactate, which signified that she was deteriorating.
asserted
she → measure → lactate
Despite this, Dr Tan determined that Amrita did not look unwell.
asserted
Amrita → determine → this
He did not attend to the eight-year-old again until 5.30am, when it was clear her condition had worsened.
asserted
condition → attend → 5.30am
Her care was escalated to senior clinicians and specialist units, but she suffered a brief cardiac arrest at 7.30am.
asserted
she → escalate → 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.
asserted
Amrita → organise → arrest
Despite efforts at CPR, she could not be saved.
uncertain
she → save → CPR
In a 2024 inquest into Amrita’s death, Monash Health admitted staff had failed to appreciate the seriousness of the girl’s condition.
asserted
staff → admit → condition
On Wednesday, Spanos determined Amrita’s death was preventable.
asserted
death → determine → Wednesday
“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.
uncertain
coroner → complete → Amrita
His actions, Spanos told the court, “thereby caused or contributed to her death”.
asserted
Spanos → tell → death
The coroner did not make any formal recommendations, instead commending Monash Health for undertaking an internal review following Amrita’s death.
asserted
coroner → make → 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.
asserted
hospital → acknowledge → 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.
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who → appear → courtroom
The couple did not speak to media as they left court.
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they → speak → court
The Aporia
