An explosive report has laid bare the failings of emergency staff at Perth Children's Hospital the night Aishwarya Aswath died — including how a temperature of 38.8 degrees and her little body becoming “floppy” were overlooked.
Among the string of mistakes made while the seven-year-old lay dying in the emergency department was staff's “failure to identify an abnormal temperature”.
Despite the high reading, it “did not prompt consideration of sepsis”.
The report, which has remained unpublished until today on the grounds of patient confidentiality, also said Aishwarya was breathing at a rate of 44 breaths per minute and had a heart rate of 150 beats per minute.
Her eyes were “discoloured”, and her blood pressure reading of 114/103 indicated she was hypertensive.
According to the 29-page document, 10 pages of which were tabled in WA Parliament last Wednesday, Mr Aishwarya's dad Aswath Chavittupara asked “how much longer it would be” about 15 minutes after they'd arrived at the world-class ED.
At that time, his daughter was “grunting in pain”, “quiet”, “clingy”, and “floppy” and told staff his daughter “was getting worse”.
After being ignored, Aishwarya's mother Prasitha Sasidharan approached clinical staff as well, and was told “there weren't many patients waiting so the parents would have been seen next”.
The shocking report states another hour and 17 minutes went by before Aishwarya was finally seen by a doctor — shortly after 7pm.
After viewing CCTV from the ED on the night of April 3, the panel behind the report said Prasitha was “noted to be pacing”, with a nurse also making the note at 5.52pm which stated: “mother anxious”.
“The panel noted five separate parental escalations to the ED clerk and clinical staff,” the report stated. “They were never aggressive.”
In spite of these observations, the report stated that the paediatric treatment guide scored the parents’ concerns at “zero”.
It says that by 7.06pm, Aishwarya couldn't raise her arms, which “looked stiff”.
It also revealed her parents were “distressed”, with CCTV showing one of them walking up to a senior doctor to once more beg for help.
Three minutes later Aishwarya was noted by a doctor to have “cold peripheries and slurred speech” when frantic attempts to save her life finally began.
Less than two hours later she was declared dead.
The parents of Aishwarya told The West Australian they had been left devastated this morning after finding out the confidential report had been leaked, saying “they wouldn't, they can't do that without our permission”.
They said it left them with only one option — to release the full confidential report themselves before they were ready.
The findings of the internal report — a root cause analysis carried out by a 10-person panel of medical experts — was sent to Aishwarya's parents last Wednesday.
While 10 of the document’s 29 pages were tabled in the WA Parliament, including 11 recommendations to be implemented by PCH within six months, the rest has remained unpublished until today.
The report also said there “were a cascade of missed opportunities to address the parental concerns and incomplete assessments” when it came to Aishwarya's treatment over the one hour and 38 minutes she was forced to wait in the emergency department.
It concluded this “may have contributed to the patient’s outcome”.
It also stated what the summary of the report, released last week, had already revealed that there was no coordinated plan when it came to Aishwarya's treatment, and that an “appropriate level of clinical supervision was not evident”.
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https://news.google.com/__i/rss/rd/articles/CBMiigFodHRwczovL3RoZXdlc3QuY29tLmF1L25ld3Mvd2EvZXhwbG9zaXZlLWZ1bGwtcmVwb3J0LWludG8tZGVhdGgtb2Ytc2V2ZW4teWVhci1vbGQtYWlzaHdhcnlhLWFzd2F0aC1sYXlzLWJhcmUtc2hvY2tpbmctdHJ1dGgtbmctYjg4MTg3Mzk5N3rSAY4BaHR0cHM6Ly90aGV3ZXN0LmNvbS5hdS9uZXdzL3dhL2V4cGxvc2l2ZS1mdWxsLXJlcG9ydC1pbnRvLWRlYXRoLW9mLXNldmVuLXllYXItb2xkLWFpc2h3YXJ5YS1hc3dhdGgtbGF5cy1iYXJlLXNob2NraW5nLXRydXRoLW5nLWI4ODE4NzM5OTd6LmFtcA?oc=5
2021-05-17 04:49:00Z
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