An eight-year-old Indian-origin girl died from myocarditis at an Australian hospital in 2022 after a junior doctor failed to recognise the severity of her condition, a Victorian coroner has found, concluding that earlier medical intervention could have saved her life.Amrita Lanka died at Monash Medical Centre in Melbourne on April 30, 2022, less than 24 hours after arriving with vomiting, diarrhoea and abdominal pain, according to ABC News.On Wednesday, Deputy State Coroner Paresa Spanos found that the care provided by overnight registrar Patrick Tan contributed to Amrita’s death. She said earlier escalation of treatment and a transfer to the Royal Children’s Hospital (RCH) could have saved her.“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 … and thereby caused or contributed to her death,” Spanos said.
How did Amrita’s condition deteriorate?
Amrita was referred to the hospital’s paediatric emergency department by her family doctor on April 29, 2022, after two days of illness. At triage shortly before 1pm, she was alert and her vital signs were within the normal range.Doctors initially suspected gastroenteritis, and she was placed in a cubicle without an allocated nurse.Later that night, her mother, Satya Tarapureddi, said Amrita began struggling to breathe. She told ABC News in 2022 that she pressed the staff assistance button but nobody came.“If they had paid more attention to her, maybe today my Amrita could be sitting next to me,” she said.Tan reviewed Amrita at about 3.20am on April 30. An electrocardiogram showed abnormal results, and he suspected myocarditis, an inflammation of the heart muscle. However, he told the inquest that he had not understood the severity of her condition.Tan said he was 12 weeks into his first paediatric rotation and responsible for about 18 patients during the overnight shift.Further blood tests were ordered, but Amrita did not receive proper attention again until about 5.30am. A troponin test, which measures heart muscle damage, returned a result exceeding 27,000 nanograms per litre, compared with a normal level below 10, the coroner said.Amrita was moved to the emergency department’s acute section, where she suffered three cardiac arrests. She died shortly after a retrieval team from the RCH arrived, as per the outlet.
What did the coroner find?
Spanos said several opportunities to intervene earlier had been missed. These included acting on high lactate levels and low blood pressure, which should have prompted a medical emergency call.She found that earlier escalation of care and transfer to the RCH, which provides specialist life-support services for children with critical heart and lung conditions, could have made the difference.By 8am, Amrita was receiving a high level of care from Monash doctors. However, Spanos said the opportunity to prevent her death had already passed.Two other doctors involved in Amrita’s treatment were cleared of responsibility.
Hospital response
Monash Health conducted its own review in 2022 and acknowledged failings in the care provided before Amrita’s death. The health service has since changed its practices and policies and improved staff education, the coroner said.In a statement, Monash Health said it would carefully consider the findings.“Since Amrita’s death, Monash Health has made changes to strengthen patient monitoring, escalation of care and communication, and we remain committed to learning and improving patient safety,” it said.During the inquest, Spanos spoke about the loss felt by Amrita’s parents and brother. She described the girl as a talented child who loved art and animals, particularly birds, and played the piano.Her mother had previously described the possibility that better care might have saved her daughter as “torture”.
