Understaffing at Perth Children's Hospital had left doctors and nurses "exhausted and demoralised" before the death of seven-year-old Aishwarya Aswath, a report has found.
Aishwarya succumbed to a fatal infection on Easter Saturday, her condition having deteriorated while her parents pleaded for her care to be elevated.
A report by the Australian Commission on Safety and Quality in Health Care has highlighted significant issues at the PCH emergency department in the months leading to her death.
The triage and waiting areas were "particularly vulnerable and suboptimally staffed", doctors and nurses were burnt out and a major increase in ED presentations was not met with sufficient urgency.
Aishwarya Aswath died at Perth Children's Hospital after waiting almost two hours to see a doctor. Source: Aaron Fernandes/SBS News
Junior staff were referred to the medical watchdog after Aishwarya's death, further damaging trust and morale and prompting unions to organise protests.
"The anguish and pain of the family were in the public domain ... the health system, the hospital and large numbers of staff at all levels, found themselves unprepared, deeply saddened and devastated," the report released on Tuesday said.
The inquiry found an unusual rise in presentations between October and December 2020 had swamped the emergency department.
A heavy reliance on recruiting nurses from interstate and overseas and low levels of full-time permanency in the nursing workforce had left PCH "particularly vulnerable" to disruptions associated with the coronavirus pandemic.
The report makes 30 recommendations, including for the hospital to improve the ways it engages with consumers, especially families from culturally and linguistically diverse backgrounds.
WA Health Minister Roger Cook. Source: AAP
“(PCH) review and progress its approach to the development, implementation and monitoring of CALD capability strategies, along with commensurate staff competence training programs,” the report said.
The report found the data on the needs of Western Australian families from CALD backgrounds is not well documented and monitored across the health system.
Minister admits staffing was insufficient
Health Minister Roger Cook had previously defended the hospital's staffing levels on the night Aishwarya died.
On Tuesday, he said the emergency department had been "fully rostered" but acknowledged it had not been sufficient.
He said the ED's staffing had been bolstered as part of a major new investment in public hospitals.
The government has accepted all 30 recommendations made by the independent committee. They include staff communication training, recognising parents' "extraordinary role in the recognition of deterioration" and minimising the use of casual staff.
Aishwarya was taken to the $1.2 billion hospital with a fever and triaged by a nurse - who did not check her vital signs - in the second-least urgent category.
Within 20 minutes of arriving, her hands were cold, her eyes were discoloured and her respiratory rate and heart rate were significantly elevated.
But a review by the Child and Adolescent Health Service found the severity of her condition wasn't recognised until an hour and 17 minutes later, despite Aishwarya's parents having raised concerns on five separate occasions.
She was pronounced dead within two hours of entering a resuscitation bay, having succumbed to an infection related to group A streptococcus.
The independent report released on Tuesday was critical of the PCH executive team for failing to endorse the internal review, saying it had created "misunderstanding and confusion with no apparent benefit".
Aishwarya succumbed to a fatal infection on Easter Saturday, 2021. Source: Supplied: Suresh Rajan
"Aishwarya's care, her extremely rapid deterioration in the ED and her tragic death has resulted in immense loss, anguish and pain suffered by Aishwarya's family and constitutes a personal crisis of unimaginable proportions," the report said.
Family wants CCTV footage released
Family spokesman Suresh Rajan said Aishwarya's parents were disappointed with the report's focus and hoped an upcoming coronial inquest would provide more answers about what led to her death.
“When Roger Cook announced the inquiry back in May, he said it was going to be a short sharp inquiry to determine the reasons why Aiswarya died. He made it very clear that the hospital and the state government had failed the parents,” Mr Rajan said.
“We don’t know who was at fault, where the mistakes were made, because that has never been addressed”.
Mr Rajan said the family is requesting CCTV footage from the hospital be released and a coronial inquest planned for 2022 be expedited.
Additional reporting by Aaron Fernandes.
