Background
Investigations following her death found that Aishwarya had died from multiorgan failure due to fulminant sepsis related to a bacterial infection (Streptococcus pyogenes, a type of Group A Streptococcus). Group A Streptococcal infections are common in children, causing symptoms such as a sore throat, scarlet fever, and school sores. However, in rare cases, infections of this kind can cause a severe illness such as rapidly progressive sepsis, which occurred in Aishwarya’s case. In children, this type of sepsis is difficult to diagnose, and without early intervention with antibiotics, can sadly often be fatal.
On 1 April 2021, Aishwarya had gone to school as normal, before coming home to play soccer with her father and siblings until dinner time. It was a normal day, and her parents did not notice anything concerning about her.
In the early hours of 2 April 2021, Aishwarya woke up and told her mother she had a headache. Her mother thought it might have just been the ice cream she had eaten the night before or due to going to bed late. They went back to sleep, but Aishwarya woke again at 6:00am still complaining of a headache. Her parents took her temperature, but it was within normal range. Her mother provided a dose of Panadol. Throughout the morning, Aishwarya vomited four times, but then seemed to settle into the afternoon.
On the morning of Saturday, 3 April 2021, Aishwarya remained unwell, complaining of a sore body, particularly her legs and hands, and saying that she felt weak. She stayed inside resting for most of the day. By the afternoon, Aishwarya’s mother was worried that she had not improved, and wanted to take her to hospital. At 4:30pm, Aishwarya’s mother noticed that her hands were very cold but her forehead was warm. At this point, they decided to attend PCH Emergency Department (ED).
They left home at about 5:00pm, driving 15 to 20 minutes to PCH. When they arrived at the ED, Aishwarya’s father noticed a large sign stating that average wait times were 4 to 6 hours, and that the hospital would not tolerate abusive behaviour. Reading this sign had a significant impact on the way in which Aishwarya’s parents behaved whilst in ED throughout the evening, when trying to get the staff’s attention. They did not want to be characterised as abusive.
Upon arrival, Aishwarya’s parents immediately approached a triage nurse and advised of Aishwarya’s condition. The triage nurse assessed the information and applied a triage score, however did not physically assess or touch Aishwarya, due to her location behind the triage desk and windows, and the fact that she was the only nurse stationed on the triage desk and could not leave it unattended. It was not common practice at PCH for a triage nurse to assess vital signs upon arrival.
At that stage, Aishwarya’s symptoms appeared to be gastrointestinal. She was assessed as triage category 4, the second lowest category, which meant she was assessed as being currently stable and should be medically assessed within one hour.
The Coroner noted that at the triage stage, Aishwarya exhibited symptoms which could have led to a diagnosis of sepsis, given her cold hands and gastro symptoms. This was said to be the first missed opportunity for anyone at PCH to realise that she was seriously unwell and required urgent treatment.
Next, Aishwarya was carried into an ED waiting room by her father. They sat on a couch and began to wait, although their instincts were telling them that her condition was serious and was not being appreciated by staff. After 5 minutes, Aishwarya’s mother approached an ED clerk and told her that Aishwarya’s eyes were showing white patches. The ED clerk immediately advised Dr T, a trainee registrar. This occurred at 5:41pm. Dr T assessed Aishwarya’s eyes for 30 seconds, but had not reviewed her triage information, so did not know of her presenting gastro symptoms. He did not consider her presentation to be concerning and went back to seeing other patients without making an immediate note of his assessment. Dr T’s brief assessment was the second missed opportunity for the PCH staff to realise the seriousness of Aishwarya’s condition.
A minute later, at 5:42pm, Aishwarya’s mother again approached the administration desk, very upset about Aishwarya, and wanting to see a doctor. Nurse V, a registered nurse, then came to assess Aishwarya. Aishwarya’s father explained her condition. Nurse V decided to prioritise Aishwarya ahead of 10 other patients in the waiting room. Nurse V carried out a 15-minute assessment, however did not notice that Aishwarya appeared ‘floppy’, because she was sitting in her father’s lap. Nurse V planned to start an oral fluid treatment and oral ibuprofen within 30 minutes but was called away for about an hour to other patients.
Nurse V did not identify or consider that Aishwarya was experiencing sepsis. Rather, her view was that Aishwarya’s condition was consistent with fever or viral illness, such as viral gastroenteritis. The Coroner found that Nurse V’s assessment was the third, and most significant, missed opportunity for a PCH staff member to identify that Aishwarya was seriously unwell and possibly septic. This was the first time that vital observations were recorded which began to point towards a sepsis pathway.
Nobody from PCH interacted with Aishwarya in the 30 minutes following Nurse V’s departure. Her parents were told there was an emergency elsewhere, occupying the doctors. Aishwarya deteriorated while they waited. At 6:45pm, Nurse V handed over to Nurse W. There was no suggestion at that time that Aishwarya’s condition was concerning. Over the next 20 minutes, Aishwarya’s parents begged staff to attend to her. Nurse W first came to approach Aishwarya at 7:05pm. Aishwarya could not lift her arms or head to consume fluids. Nurse W immediately went to get Dr H, an ED Consultant. Dr H asked that Aishwarya be prioritised, moved to a bed and thoroughly assessed within 10 to 15 minutes. Aishwarya’s father carried her to a bed, where Nurse H and Nurse D immediately recognised that her condition was poor, displaying hypertonic arms and legs, yellow/discoloured sclera in her eyes, and appearing confused and catatonic. They immediately discussed moving her to the resuscitation bay.
Aishwarya was moved to the resuscitation bay at 7:30pm. Dr H joined Nurse H and Nurse D as they wheeled the bed. Dr H noticed that Aishwarya appeared far worse than when he had seen her less than 30 minutes earlier, indicating a sign of a very rapidly progressing disease. Aishwarya was given intravenous fluids, antibiotics and other medications between 7:45 to 7:50pm. She appeared to briefly stabilise, but then had a large vomit. Dr H gave evidence at the Inquest that a vomit can cause a brief drop in blood pressure, making a patient haemodynamically unstable. Dr H felt this may have occurred in Aishwarya’s case, as shortly after she went into cardiac arrest. Cardiopulmonary resuscitation (CPR) was administered. After 43 minutes of CPR, Aishwarya could not be revived.
The Inquest was held to determine (1) whether Aishwarya’s death was preventable if she had received earlier medical treatment at PCH, and (2) to explore what happened and ensure that lessons are learnt from her death from a public health and safety perspective.
Outcome
The Coroner ultimately determined that there were a number of missed opportunities for someone to have intervened at an earlier stage, although nobody could say that earlier intervention definitely would have saved Aishwarya. Similarly, nobody could say that there was no chance she could have been saved. The Coroner was satisfied that on the evidence before her, there was a small possibility that if proper, urgent treatment had been initiated earlier, perhaps by the time Nurse V assessed her, Aishwarya’s life might have been saved.
During the course of the Inquest, evidence was called from two expert witnesses, which appear to have informed the Coroner’s finding:
- Dr S, an Infectious Diseases Physician, opined that if antibiotics and fluid resuscitation were provided at an earlier stage, Aishwarya may have had a small chance at survival. Put another way, Dr S could not say with absolute certainty that she would have died anyway. Dr S noted that indicators of sepsis were present, but due to a number of factors, including the experience of the staff assessing Aishwarya, and their busyness that evening and availability to monitor her, those indicators were missed. Dr S said that by the time her condition was identified and treatment was commenced, it was clearly too late.
- Dr N, a Specialist Consultant Paediatrician, opined that on the balance of probabilities, it was unlikely that the outcome would have been any different. However, like Dr S, Dr N could not say with absolute certainty that Aishwarya wouldn’t have survived if she had received appropriate treatment within the first hour.
It was acknowledged that, even if Aishwarya had survived, there may have been extreme damage to her organs or other complications that would have eventually led to her death.
It is also important to highlight that all of the PCH staff gave evidence at the Inquest as to how severely understaffed and busy PCH was at that time. It was clear that the staff had, for a long time, been placed under overwhelming working conditions, particularly in light of the COVID-19 pandemic. Evidence from the staff demonstrated that, in the months prior to Aishwarya’s death, complaints had been made to the PCH executive about workloads and concerns for patient safety, but those issues had gone unresolved.
Lastly, the Coroner acknowledged that presently, doctors and researchers still do not have a clear understanding of why some patients develop invasive Group A Streptococcal infections and others do not.
Recommendations
The Coroner concluded her findings by making a number of recommendations to various stakeholders, as follows:
- The Department of Health/CAHS commit to an early implementation of nurse/midwife-to-patient ratios, ensuring a minimum ratio is put into place for emergency departments as a matter of priority.
- CAHS prioritises the implementation and staffing of a supernumerary resuscitation team in the ED of PCH.
- The WA Government consider introducing ‘safe harbour’ legislation to protect nurses from Ahpra investigation and prosecution when an adverse event occurs in the context of nurses working where there are known risks which have not been rectified by the employer.
- The State Government priorities funding for the Department of Health to implement digital tools to make it easier for staff to document / record information and access medical records.
- CAHS give consideration to changing triage procedures, to implement observations being taken at the triage stage, or within 30 minutes by a waiting room nurse when children present with gastrointestinal symptoms. This would ensure there was an early benchmark to measure the child’s progress and monitor for signs of sepsis.
Many important changes have already been implemented since the tragic passing of Aishwarya, however the Coroner concluded by posing that it should not have taken the death of a young child to have triggered such fundamental changes.
