Aishwarya Aswath: 13 things we learned after inquest into girl’s death at Perth Children’s Hospital

The inquest into the death of Aishwarya Aswath was all about symptoms. Symptoms of a critically ill little girl that weren’t spotted in time. And symptoms of a very sick health system that were known but weren’t acted on in time. Over nine days, those symptoms — physical and systemic — were laid out in detail and in full. Legal affairs editor Tim Clarke listened to them all, and explores what they revealed about the little patient who needed help and the health system which wasn’t well enough to provide it. 1. FAMILY Aswath and Prasitha – intelligent, loving, committed, hard-working parents enjoying their life – and the family which was their life. Little Aishwarya, beloved daughter and sister, who had finished school for the term and with Easter on the sunny horizon. She was bright, sunny, smiley, particularly close to her sister Amrita, with whom she shared their special secrets. They did magic tricks together, and were even planning on setting a YouTube channel to show them off to the world. After a game of soccer in the front garden, and then dinner, the school holiday was started with a special treat - a walk to Baskin- Robbins for ice-cream. That was followed by a family tradition – ‘carpet room night’ where the whole family would push mattresses together and then sleep together, under the air-conditioning. “They had so much fun, and when they came back from school they were all happy and excited. There was nothing out of the ordinary,” her father Aswath said. Until the Friday morning, when Aishwarya woke up feeling under the weather. 2. ILLNESS The seven-year-old was complaining that she felt weak, she felt sore, and she felt sick. She was sick, and barely ate, forcing down some rice soup before returning to the couch. On Saturday morning, she was still unwell and so Aswath bought her favourite cereal – Coco Pops. She ate them, but not with any relish. And they didn’t seem to help. Neither did the paracetamol. Worried all day, her mother Prasitha began suggesting a trip to the hospital. Aishwarya really didn’t want to go, and insisted she was feeling better. But her parents knew her better. They knew she wasn’t right. Then at 5pm, the little girl with the warmest smile developed really cold hands. That made her parents’ mind up. They could go to Midland hospital but they wanted to make sure their little girl got the best treatment. So they left their other children with Aswath’s mother, put their daughter into the car and set off for Perth Children’s Hospital. 3. NURSES At 5.35pm, having tried to warm up those cold hands in the car, Aswath carried his daughter through the doors of PCH, into what appeared to be an empty waiting area in front of the one nurse behind the glass and a desk and a computer. One sign which greeted them cautioned of a wait of between four and six hours. Another warned that the hospital would not tolerate abusive behaviour. That lone nurse, Jacqueline Taylor, was on triage duty – the first port of call, the very front line, the first to see anyone who walked in the door. She would greet 96 patients, along with parents, that shift and have to assess every one of them. And that wasn’t her only job. She had to escort more serious patients straight through. She had to let family members through. And so time was in short supply. Her assessment of Aishwarya took just over two minutes, from behind that desk and that screen. It didn’t involve a touch, or a taking of temperature. Just some questions – about symptoms, about pain, about concerns. Having listened, she made the quick call she was required to make – a score of four, the second-lowest on the chart. 4. DOCTORS In the waiting room, Aishwarya lay in her father’s arms while he sat and waited and her mother paced. The floor a vibrant green, the chairs a vivid pink. The area awash with colour. But it was another fleck of colour – white specks that had appeared in Aishwarya’s eyes, which were really worrying her parents. They weren’t there before, but they were there now. Prasitha felt she had to say something, so she told a clerk, who told a nurse, who told a doctor. That was Dr Tony Teo, a junior registrar who had earlier been told there were several doctors off sick, and he needed to get into Pod C – where the not-so-sick kids were waiting - and get cracking. He was told there were a set of parents who were worried about their child’s eyes, and so he went to look at her eyes. That look took just 19 seconds. There was no apparent trauma, no yellowish tinge, no burst blood vessels. And so he didn’t think there was much wrong. Having not checked the brief triage notes, he didn’t know about the other symptoms – didn’t know the eye issue was new. He also didn’t really notice how floppy the little girl was. Or how cold her hands were. Or how dry her lips were. “I had other patients I was attending to,” Dr Teo said. 5. CHAOS There were 200 other patients through those doors that day. And their parents. And their siblings. And as had been the case for at least six months, the staff were spread so thin as to be transparent. Three doctors had called in sick, along with a nurse. The remaining doctors and nurses were looking after their patients right in front of them, while crushingly conscious of all the others to come. And one of those in the queue was the little girl in the corner with her quiet, polite but concerned parents. Nurse Tahnee Vining was one of those nurses who was trying to hold it all together. She had graduated just over a year ago, but was still senior enough to have a student shadowing her that night. She was assigned to the waiting room, but was also floating into other areas when needed. And if an emergency was called, requiring a resuscitation, she was part of that team as well. But before that, there were 20 patients on her list. And the concerns of Aishwarya’s parents meant she jumped to the top of that list. For just over 10 minutes. She took Aishwarya’s temperature – 38.8C. Pretty high. Her breathing – pretty high again. Her heart rate – 150bpm – high again. She also looked dehydrated. A sick child, for sure. One in need of fluids, and pain relief, and some tests. And someone to keep an eye on her. That was the plan. But at around 6pm, a resus call went out. And then another. Some blood needed to be taken from a child going into surgery. And another child was on the way in an ambulance with potential spinal injuries. So Ms Vining’s priorities changed. Or were changed for her. “As a junior nurse, when I first started I would not say no to anyone, I feel like there was lot of pressure to keep going and keep going,” Ms Vining said. “I think if I had have been present in the waiting room and been able to finish her assessment, I would have been able to recognise the deterioration and recognise the severity of her illness. “I did the best I could in the situation with what we had.” 6. REALISATION It took Ms Vining nearly an hour to return. And when she did she had to write up the notes. Notes she had written on her arm to start with. The PARROT chart – the chart which was one of a few nurses had to fill in – was written up. But not completed. And the back page, the one which made suggestions that if certain symptoms were seen together, then maybe sepsis should be considered, was lost in the midst of no time. Nurse Vining, creaking under the pressure, handed over to her colleague Caitlin Wills who took up the case and attempted to act on a part of the plan. Her very first interaction with the little girl lying on the chairs in the corner. She wanted to give her some pain relief. And she wanted to see if Aishwarya could take it herself. But under pressure herself, she barely looked at or spoke to the parents. Having been waiting and worrying for more than an hour, those parents found the nurse rude. And seemingly uncaring. But when the little girl couldn’t sit up, or barely say a word, Ms Wills was the first to feel the hackles of something else going. Something more serious. She voiced her concerns to one of the doctors in charge, William Hollaway, a consultant coming out of one of the busiest periods he had ever seen in the hospital. Also exhausted, also frustrated, he was also concerned enough to say that Aishwarya should be put in a cubicle right away. But then he was called away, to have a look at a sick baby. By the time he got back, things had gone as bad as they could possible go. 7. RESUS Nurse Sarah Hanbury had been so busy that night that she had only been doing anything by half. But when the little girl turned up in her area, she went to work. With obviously stressed parents in the room, she thought the best would be to go straight to the little girl and see what she could find out, what she could do. What she saw was a very sick little body. Dry cracked lips, fast breathing, a yellow tinge in the eyes and not the answers she was expecting. Just questions – about how sick this little girl really was. The answer to her own question was very sick – sick enough to move her again, to a resuscitation room where the full force of the department could be called in to help. And when they were, and tests quickly done, the results were horrifying – sky rocketing acidosis in Aishwarya’s blood, showing her little body was starting to fail her. A tube in the back of the hand was inserted at the first go, so antibiotics could be pumped in. Aishwarya’s jaw was so stiff it was hard to get a breathing tube in. And then she vomited violently. And then her heart gave up. And despite round after round of adrenaline, and minute after minute of CPR, it couldn’t be started again. 8. AFTERMATH “That was a terrible night,” was how Dr Hollaway remembered it. “It affects me a lot,” was Tahnee Vining’s summation. Dr Michael Hale, another involved in the resuscitation attempt, said the team “did everything we could to save her life”. But it wasn’t enough. Aishwarya’s parents had to tell her brothers and sisters she wasn’t coming home. Had to teach themselves how to live without her. Before they told the story how they had taken a sick little girl into the State’s state-of-the-art children’s hospital, and had been left waiting, and then grieving an unimaginable loss. The reaction in public was visceral. The reaction in the hospital caustic. A Root Cause Analysis inquiry was ordered, with interviews conducted with staff involved on the night. And that process left those staff feeling more broken than before. They said interviews felt more like interrogations. There was no chance to review what they had said, and then felt their recollections were not reflected properly. And then when Ms Vining and Ms Wills, along with a doctor, were reported to national health regulator AHPRA, bitterness piled on top. Dr Aresh Anwar – the CEO of the hospital – said that was the hospital management meeting their professional obligations. 9. CHANGES Dr Anwar hadn’t actually been sitting in the top chair on the night of April 3. Weeks earlier he had been seconded to help in the State’s rollout of the COVID vaccination to millions of West Australians. But 10 days after Aishwarya’s death, he moved back, to attempt to handle another crisis – one that had been had been brewing while the severe acute respiratory syndrome coronavirus 2 had been spreading. It had been that virus which had begun to impact his hospital, even when cases in WA were close to zero. The State’s isolation and attitude had actually meant less patients in the shiny new $1.2b facility, which had meant casual nurses who usually filled the gaps had been let go. And then when an unusual and unseasonal spike in respiratory patients had begun flowing in later in that year, the staff that were left were slammed. By October 2020, concerns were so acute that staff had begun begging for help. And while attempts were being made, staff were not told about them – and so felt ignored and unloved. The issue rumbled on, and by March nurses were desperate. A letter to their union could not have been more clear. “There are multiple examples of an unsafe environment in ED. Our concerns are consistently downplayed, dismissed, or outright ignored by the executive team,” the letter said. 25 days later, Aishwarya Aswath was dead. 10. POLITICS With the pain, came the politics. And within days of Aishwarya’s death becoming public, the State Government was on the defensive. Premier Mark McGowan backed his health minister Roger Cook, while insisting information provided by the hospital showed staffing levels on the night Aishwarya died were “basically above what’s normally there”. Mr Cook told Parliament that chief executive of the Child and Adolescent Health Service had told him that “lack of staff was not a contributing factor on the evening”. An independent inquiry pulled the cubicle curtain back a little further, pointing to the tension between staff and hospital management. But Roger Cook insisted that the hospital “performs extremely well and people can be very confident of it.”. While the resignation of chair of the board of CAHS Debbie Karasinski was accepted, Dr Anwar stayed in his position – despite an offer to leave. He did leave eventually, a matter of weeks before the inquest began. But that didn’t stop him from becoming the first witness to give live evidence – during which the hospital’s problems were laid bare. “It was an organisation that was very, very fragile in terms of integrity and working as a team,” he said. 11. REALITY To battle that fragility, the hospital went for strength in numbers. A doubling of nursing staff in the emergency department. More triage staff. More waiting room staff. More doctors. But those numbers were on paper. Getting them into scrubs and onto the floor, proved difficult if not impossible. Closed borders, both interstate and international, cut off one of the main pools of talent WA hospitals had turned to in the past. And calmer, COVID-based jobs – contact tracing and administering injections – were more attractive to the State’s nursing cohort than double shifts and distressed parents. “The biggest thing is that not much has changed to be honest,” said Cathryn Davies, the nurses whose hands tried to pump life back into Aishwarya. “We are still extremely busy. We are not covered enough if (resuscitation) cases come in … and it’s going to happen again.” 12. CORONER Preventing that was what coroner Sarah Linton said was at the forefront of her mind in hearing the evidence before her. Because of all the problems laid out over nine days of evidence, the one at the heart of it was that a little girl had died. And there had been a string of missed opportunities to save her. “There was a demand that was unprecedented, the hospital was trying to respond … to very appropriate concerns about patient safety,” Ms Linton said. “Even in that sense, I don’t think there is any intention to blame any individual. There were reasons why, everyone was trying to do their best and trying to come up with solutions. “But that doesn’t mean I won’t make comments in the findings that more could have been done, at a different time, at an earlier time. “I understand why it happened. But the problem is a little girl died, and we all have to reflect on that to make sure it doesn’t happen again.” 13. FAMILY And so Aishwarya’s family is left with some answers. But several lingering questions. Why did it have to happen to her? Why did it have to happen at all? And why did it take the death of their little girl for the changes to happen? “Our daughter had big dreams in life and always dreamt of becoming a teacher, she often said when I grow up I want to be a teacher – she was in fact a teacher for her younger brothers,” they said. “She also became the youngest ever teacher because of the circumstances of her death that should serve as a lesson for all of us to abide by – and this is especially so for our WA health system. “We will never forgive our health system and the people associated with it; since Aishwarya passed away there has not been a day without tears in our eyes. “Everything we have heard in the last few days has confirmed that there is much in the system that still needs to change.”