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, in the paediatric emergency department of Monash Medical Centre 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.
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She → present → pain
Testing quickly ruled out appendicitis, so staff began working on the basis she had gastroenteritis.
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she → rule → gastroenteritis
But early the next morning, Amrita's mother Satya Tarapureddi raised concerns the girl had chest pain and shortness of breath.
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girl → 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.
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she → undergo → myocarditis
He consulted with another colleague who agreed with his preliminary diagnosis.
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who → consult → diagnosis
The coroner has ruled that the death of Melbourne schoolgirl Amrita Varshini Lanka was preventable
Amrita's parents Chandra Sekhar Lanka and Satya Tarapureddi fought back tears at Wednesday's inquest
But neither doctor seemed to appreciate the severity of Amrita's condition, the coroner said.
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coroner → rule → condition
Amrita's blood pressure was not measured at that time but other testing showed elevated lactate, which signified she was deteriorating.
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she → measure → lactate
Despite this, Dr Tan determined she did not look unwell and he did not attend to her again until 5.30am, when it was clear her condition had worsened.
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condition → determine → 5.30am
Her care was escalated to senior clinicians and specialist units but she suffered a brief cardiac arrest at 7.30am.
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she → escalate → 7.30am
Staff 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.
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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 young girl's condition.
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staff → admit → condition
On Wednesday, Ms Spanos determined Amrita's death was preventable.
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death → determine → Wednesday
Amrita died from lymphocytic myocarditis, or inflammation of the heart muscle, in the paediatric emergency department of Monash Medical Centre on April 30, 2022
Chandra Sekhar Lanka and Satya Tarapureddi have spent the last four years fighting for justice
'
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Lanka → die → justice
Certainly by about (4am), when the ECG had been completed and the elevated lactate was available, Amrita's life could have been saved,' the coroner said in her findings.
uncertain
coroner → complete → findings
'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,' the coroner said.
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coroner → accept → Amrita
'(His actions) thereby caused or contributed to her death.'
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actions → cause → death
The coroner did not make any formal recommendations, instead commending Monash Health for undertaking an internal review following Amrita's death.
Ms 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.
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hospital → make → 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
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