The actions of a junior doctor working in a busy emergency department contributed to the death of a young girl whose life could have been saved, a Victorian coroner has found.
Amrita Lanka, eight, died from myocarditis in 2022 after arriving at the paediatric emergency department of Monash Medical Centre in Melbourne's south-east.
On Wednesday, Deputy State Coroner Paresa Spanos found Amrita's death was preventable and that the doctor in charge, Patrick Tan, did not appreciate the severity of the girl's symptoms in the early hours of April 30 that year.
"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," Magistrate Spanos said.
She choked up and took a long pause as she described how Amrita was deeply missed, especially by her father Chandra Sekhar Lanka, mother Satya Tarapureddi and her brother.
"Satya described her daughter as the most precious, talented and beautiful child who loved art and animals, especially birds. Amrita played the piano, was very smart and was the centre of their universe," Magistrate Spanos said.
The events leading up to Amrita's death
Amrita was referred to the emergency department on April 29, 2022 by her family doctor after two days of nausea, vomiting, diarrhoea and abdominal pain.
Magistrate Spanos said Amrita was alert and that her vital signs were in the normal range when she was triaged shortly before 1pm.
Less than 24 hours later, Amrita was dead.
Magistrate Spanos said doctors made a working diagnosis of gastroenteritis.
The girl was placed in a cubicle that did not have an allocated nurse.
Later that night, Amrita's mother said her daughter experienced "hard breathing".
"She told me, 'Mama, hard breathing, hard breathing'. Then immediately I pressed the staff assistance button but nobody came," Ms Tarapureddi told the ABC in 2022.
The court heard that Dr Tan, the overnight registrar, conducted a review at about 3:20am on April 30.
An electrocardiogram test returned abnormal results, the court heard.
Dr Tan suspected Amrita was suffering from myocarditis, but told the inquest he did not appreciate the severity of her condition.
Dr Tan, who was 12 weeks into his first paediatric rotation, said he was in charge of about 18 patients during his shift.
Further blood tests were ordered but no-one properly attended to Amrita until about 5:30am.
A troponin test, which measures heart muscle damage, came back at more than 27,000 nanograms per litre. The normal level is below 10, the coroner said.
Amrita was transferred to the acute section of the emergency department and suffered three cardiac arrests, the last shortly after a retrieval team from the Royal Children's Hospital arrived.
Magistrate Spanos said Amrita was receiving a high level of care from Monash doctors by 8am on April 30.
But by then, she noted, "the die was already cast".
Life-saving opportunities missed, coroner finds
Magistrate Spanos said Amrita's life could have been saved with "timely escalation" and an earlier transfer to the RCH, which had specialised life support services for children with critical heart and lung conditions.
Other missed opportunities for doctors included high lactate levels detected in a blood test and a low blood-pressure reading that should have triggered a medical emergency call.
Monash Health had made changes to practices and policies and improved staff education, the coroner said.
Two other doctors involved in Amrita's care were cleared.
Monash Health conducted its own review in 2022 and admitted failings in the lead-up to Amrita's death.
At the time, Ms Tarapureddi said it was "torture" knowing Amrita might have lived if she received better care.
"Do you know how painful and unbearable [it is] when a child dies in front of us, the parents?" she said.
In a statement, Monash Health said it would carefully consider the coroner's 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.
In 2024, the Victorian government trialled a telephone hotline for parents to ring if they believed their children were receiving inadequate care in hospital.
The Kids Urgent Concern Helpline was expanded state-wide in July this year.
