The Inquiry’s terms of reference encompassed issues about the care and treatment provided to Aishwarya Aswath prior to her death in April 2021, the conduct of the root cause analysis undertaken at the Hospital following the death, ED staffing and patient flow models, the roles and responsibilities of clinicians, management and the Executive at the Hospital, PCH’s clinical incident management processes and the performance of PCH in relation to safety and quality measures as compared to national peers.
In preparing the Report, the Inquiry Panel held interviews with clinical and administrative staff, board members, internal and external expert consultants, as well as Aishwarya’s parents and their support person. The Panel also received over 3500 documents for review.
At the outset, the Report noted that Group A Streptococcus (GAS) was identified in Aishwarya’s blood and tissue and the cause of death had been confirmed as multiorgan failure due to fulminant sepsis. It was also noted that sepsis is a time critical medical emergency and deterioration can be rapid and unpredictable, particularly in children. The Report acknowledged that sepsis can be difficult to identify as symptoms can be common to many other, less consequential, conditions.
Whilst identifying a number of systemic gaps and areas for improvement at the Hospital, the Report also identified that during the last quarter of 2020 the PCH ED became the busiest Paediatric Emergency Department in the nation, showing the highest number of ED presentations per nursing FTE over the past two years. The extraordinary rise in activity in late 2020 then further exacerbated nursing workforce issues. The Hospital’s historic reliance on national and international recruitment of staff, particularly nursing staff, compounded workforce issues when border closures limited recruitment opportunities.
A key finding of the Report was the importance of the role of families for the care of a child. It was found that it was an essential component of paediatric care to listen to the parent and appreciate the role of the parent in recognising early signs of illness or deterioration. This finding is reflective of the fact that prior to her daughter’s death, Aishwarya’s mother attended the waiting room desk on 5 occasions to seek assistance for her daughter.
Recommendations were also made with respect to identifying and monitoring health care utilisation by culturally and linguistically diverse (CALD) patients and families and increasing staff competence in communicating with CALD families. The Panel noted that whilst the Call and Respond Early (CARE) call system had been implemented in WA inpatient settings, it had not been implemented in EDs at the same time. It was recommended that the CARE call system as adapted to ED settings be progressed, evaluated and rolled out across multiple WA locations.
Whilst the Report does highlight a number of issues at PCH to be addressed, it also noted that key measures of hospital-wide safety and quality are exemplary and PCH has often performed better than peers in measures of ED wait times, average length of stay and ED admission rates.
To read the full Report, click here.
