What has changed at Perth Children’s Hospital since the death of Aishwarya Aswath?

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The death of Aishwarya Aswath at one of Australia’s top children’s hospitals shook the faith of parents everywhere.

The seven-year-old was in the best place for a sick child—the emergency room, staffed by medical specialists trained to evaluate and treat serious illnesses.

But opportunities were repeatedly missed to establish just how ill she was when she died of sepsis in her father’s arms in the waiting room.

An inquest into her death concluded last week, with the coroner pointing her findings to “missed opportunities” in Aishwarya’s care.

Many Western Australian parents wonder what would happen if their own child were seriously ill and they had to rely on the same system that failed Aishwarya and her family.

So what were the weak points and how would it be different if another sick child sought help in the hospital today?

The triage desk

When Aishwarya was brought to the ER at Perth Children’s Hospital by her father, triage nurse Jacqueline Taylor was trying to juggle three jobs at the same time – triage nurse, concierge and escort for patients who were triaged 2 or higher.

She spent three minutes judging Aishwarya, and in that time two other families and a parent came wanting her attention.

Aishwarya’s parents said she suffered from body aches, but this information was not shared with Ms Taylor.

She also didn’t take vital signs, including temperature – something explained by the layout of the triage area, placing her over a large desk and separated from the family by a plastic screen as she entered information into the computer system.

Aishwarya’s parents, Aswath Chavittupara and Prasitha Sasidharan, testified at the inquest.(ABC News: Andrew Willesee)

There is also no single cubicle area where a child in triage can be examined more fully.

Ms Taylor told the inquest that if she had been given the time to examine Aishwarya more thoroughly it “could have changed the way she cared”.

Aishwarya’s parents told the inquiry that upon entering the hospital, they were greeted with signs saying wait times were 4 to 6 hours and a warning that aggressive behavior would not be tolerated – something that may be the nature and ways in which they communicated their concerns about their daughter. They were persistent but also very polite and respectful.

What has changed?

Since Aishwarya’s death, Perth Children’s Hospital has hired an additional front-door triage nurse.

They have also changed the scoring table, bringing the nurse closer to the patient and family, although the practice of not taking vital signs, including temperature, during triage remains.

A long shot of Perth Children's Hospital with stained glass windows and a sign.
Aishwarya’s death sparked several changes at the hospital. (ABC News: Keane Bourke)

There is also a specific triage policy now in place, but Ms Taylor said she would not have changed her assessment had it been in place when Aishwarya entered.

Parents are now greeted with a large sign that reads “Welcome to PCH” in different languages.

There are screens that provide information about who each employee is and what their uniform looks like, and what people can expect to see in the ER.

What problems remain?

Ms Taylor warned that while things have changed in ED, “I don’t think they’re up to the ideal standard anymore,” ailing staff are still under pressure.

She agreed with the coroner that the electronic information system used to record patient notes was not really “serviceable” with many areas left blank and some duplicated.

Nurse Jacqueline Taylor outside wearing a black COVID mask in front of the coroner.
Triage nurse Jacqueline Taylor was trying to juggle three jobs at once when Aishwarya arrived at PCH.(ABC News: Andrew Willesee)

And Ms Taylor said if equipment was made available to her, she would take patients’ temperatures and heart rates, which she had done in a previous role at Broome Hospital, which she thought was helpful.

It is still not hospital policy to take measurements during triage.

The waiting room

Aishwarya was triaged with the relatively low score of 4 and sent to a low priority area of ​​the waiting room.

She was first seen by Doctor Tony Teo, a junior doctor working in a different ER unit that night, who was shut down by a staff member after her parents raised concerns that her eyes were discolored.

He did not check her triage notes, but looked her in the eye for about 20 seconds and noticed some white spots, but concluded that this was not an urgent issue and could be followed up later.

About 15 minutes later, she was seen by nurse Tahnee Vining, who took her vital signs, including a high temperature.

Ms. Vining indicated that elevated temperatures were common in children presenting to the emergency room.

Headshot of a smiling young girl
Aishwarya died after waiting two hours in the emergency room for treatment. (abc news)

So when she filled out the PARROT (Pediatric Acute Recognition and Response Observation Tool) chart, which recommends considering further evaluation for sepsis and escalating treatment at temperatures above 38.5 degrees Celsius, she didn’t follow the advice.

But Ms. Vining stated that if she had acted on the PARROT horoscope recommendation, she would be constantly consulting with senior nurses who themselves were under extreme time pressures.

Ms. Vining also left the emergency room for almost an hour between taking Aishwarya’s vital signs and recording them in the hospital’s electronic records.

“I think if I had been present in the waiting room after the assessment and could have finished the assessment, I could have seen her worsening and the severity of her illness,” she told the court.

What has changed?

Ms. Vining left the waiting room to attend to other urgent matters.

Since Aishwarya’s death, the government has given ED an additional $20.5 million. They hired an additional 46 nurses, doubling the existing team.

A red sign with the words
Staff remain concerned about the workload and pressure in the ER.(ABC News: Keane Bourke)

Two nurses are now assigned to the waiting room to avoid staff being approached with medical concerns.

PCH has also hired 12 more junior doctors and 20 board doctors, which may ease the pressure on practitioners like Dr. Teo mitigates.

What problems remain?

But while the chief of medical services for the Child and Adolescent Health Service, Dr. Simon Wood testified that “to the best of my knowledge and belief [his] Knowledge” nurses could remain in the waiting room was still pulled out to be part of the resuscitation team, according to the investigation.

A man in a suit walks next to a woman, both wearing face masks
Simon Wood was among those who testified at the inquest.(ABC News: Cason Ho)

Ms Vining was part of the emergency department’s CPR team when she examined Aishwarya and had to be present when another patient arrived with suspected spinal injuries.

The hospital has funded positions for a dedicated resuscitation team but has yet to fill them as management says it’s a tough recruitment environment.

The resuscitation area

Aishwarya was examined by a senior doctor at around 7:10 p.m. He immediately had her transferred to a ward and taken from there to the resuscitation area.

A review by pediatrician Sathiaseelan Nair concluded that Aishwarya’s resuscitation was adequate and of a high standard.

It seems that when the staff realized how advanced Aishwarya’s illness was, all systems kicked into action and she received a high level of care.

The most significant incident in the resuscitation area was that a blood gas analyzer could not be used because it was undergoing a cleaning cycle, which delayed these results by approximately 15 minutes.

What has changed?

A second machine was purchased for the resuscitation area.

What other improvements have been made?

dr Wood pointed out that the hospital has since switched to a “flex down” rather than “flex up” staffing model, making it less likely to run out of staff when people call in sick.

However, the investigation revealed that the system used to forecast staffing needs relied on historical numbers and was not very flexible.

WA Health continues to use the existing model rather than the patient-to-staff ratio favored by the nurses’ union.

dr Wood also outlined the implementation of patient flow improvement teams beginning back in 2020, including changing the layout of general pediatric wards to make them more efficient, employing more specialists after hours, meetings where noted that something is preventing patients from being discharged and helping to free up beds.

An internal and external review has also been conducted since Aishwarya’s death.

dr Wood said the hospital acted on the recommendations in those reviews, but it “didn’t just stop receiving the reviews.”

“We tried to think very critically about what changes need to be made,” he said.

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