Coroner's Court of Western Australia

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

Delivered on : 22 February 2023

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations :

Recommendation 1

I recommend that the Department of Health/CAHS commit to early implementation of nurse/midwife-to-patient ratios in replacement of the current NHpPD model in Western Australian public hospitals, as advocated for by the ANF. Particular focus should be given to ensuring a minimum ratio is put in place in emergency departments as a matter of priority, given the known risks to patient safety from missed care in this setting. 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, as suggested by Professor Della in his Addendum to his Final Report.

Recommendation 2

I recommend that CAHS prioritise the implementation and staffing of a supernumerary resuscitation team in the ED at PCH.

Recommendation 3

I recommend that the WA Government 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

I recommend that the State Government prioritise funding the Department of Health’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. This will significantly enhance patient safety in our public hospitals.

 Recommendation 5

I recommend that CAHS give consideration to 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. This will ensure there is an early benchmark to measure the child’s progress and monitor for signs of sepsis.

Orders/Rules : N/A

Suppression Order : N/A

Summary :  Aishwarya Aswath Chavittupara (Aishwarya) was 7 years old when she died in the Emergency Ward of Perth Children’s Hospital on Saturday, 3 April 2021. She died from multiorgan failure due to fulminant sepsis (streptococcus pyogenes).

Aishwarya had become unwell at the start of the Easter school holidays and had spent Friday resting. Her parents initially thought she had a viral illness, but on the Saturday she did not improve and her parents became worried. At 4.30 pm in the afternoon, her mother noted that Aishwarya’s hands were cold and her forehead felt very warm, so her parents decided to take her to Perth Children’s Hospital.

They arrived at PCH at about 5.30 pm and were triaged immediately. After a brief triage assessment, the triage nurse felt that Aishwarya’s symptoms suggested she probably had a viral gastrointestinal illness, which is a common reason for children presenting to the PCH ED. Aishwarya was triaged as a category 4 patient and the family were sent through to the ED waiting area. Based upon the triage score, it was indicated that her case was not considered to be urgent. According to the standard, she should have a medical assessment within one hour. However, the waiting area was full and busy, which meant that the wait was likely to be longer.

Not long after taking a seat in the waiting area, Aishwarya’s mother approached a ward clerk and said that she was concerned about Aishwarya’s eyes. The ward clerk spoke to a doctor, who came over and looked briefly at Aishwarya’s eyes. He did not ask if she had any other symptoms and did not have an opportunity to look at her records, so he assumed her presenting complaint was due to her eyes only. The doctor did not see anything concerning about her eyes, so he returned to his other duties on the assumption Aishwarya would be seen by other health staff in due course.

A minute or so after the doctor left, Aishwarya’s mother again approached a ward clerk with her concerns. The clerk spoke to the waiting room nurse, who agreed to go and see Aishwarya and her parents immediately, given they were concerned. The nurse, accompanied by a student nurse, went to see Aishwarya at 5.50 pm. She took Aishwarya’s observations, which were not immediately alarming. The nurse made a plan to give Aishwarya some fluids and ibuprofen and then monitor her to see if she improved. However, the nurse then got called away and she did not commence her treatment plan. She also did not enter Aishwarya’s observations into the medical records at that time.

The nurse eventually got an opportunity to enter Aishwarya’s observations into the records at about 6.45 pm. The information she entered should, in hindsight, have prompted the nurse to seek a senior nurse review and take some other actions, but she was busy and relatively inexperienced and she didn’t appreciate at the time that this was required. Instead, the nurse handed over Aishwarya’s care to another nurse while she went on her break, with the suggestion that she give Aishwarya the fluid trial and ibuprofen she had planned earlier.

Aishwarya’s parents had been watching Aishwarya deteriorate over this time, and they had been continually trying to get someone to come and see her again, without success. When the nurse who had taken over Aishwarya’s care finally came to see them at 7.05 pm, they were very anxious. The nurse started to give Aishwarya the fluid and ibuprofen and they tried to help, but the nurse asked them to leave it to Aishwarya to take on her own. It quickly became apparent that Aishwarya was too weak to take the medication without assistance, and the nurse decided to go and ask a doctor to review her. A senior doctor came and took a brief look at Aishwarya and then directed that Aishwarya be taken through into a treatment room for more observations to be taken and a proper assessment to take place.

Once Aishwarya had been taken into a treatment room, it quickly became apparent that she was very unwell. She was taken into a resuscitation area and shortly after she collapsed. Intensive resuscitation efforts were made, but ultimately Aishwarya could not be saved. Her death was confirmed at 9.04 pm.

Extensive post mortem investigations identified that Aishwarya died from fulminant sepsis that had developed as a result of a bacterial infection caused by the microorganism Streptococcus pyogenes, a type of Group A Streptococcal infection. This type of sepsis can be difficult to diagnose, particularly in children, and without early antibiotic treatment it is often fatal.

An inquest was held on 24 August to 2 September 2022 to determine whether Aishwarya’s death was preventable if she had received earlier medical treatment, as well as to consider other issues from a public health perspective. The inquest took into account the results and recommendations of a Root Cause Analysis (SAC1) and independent inquiry that had already been conducted into Aishwarya’s death prior to the inquest.

The Deputy State Coroner found that death occurred by way of natural causes.

Based on the expert evidence, 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.

The Deputy State Coroner made five recommendations arising from the investigation into Aishwarya’s death.

Catch Words : Discretionary Inquest: Adolescent Health: Sepsis; Group A Streptococcus.

Last updated: 2-Oct-2023

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