Coroner finds girl's hospital death was preventable

Amrita died from lymphocytic myocarditis, or inflammation of the heart muscle, in the pediatric emergency department of Monash Medical Centre on April 30, 2022.

She had presented at the emergency department about 1pm on April 29, following two days of stomach pain, nausea and vomiting.

Testing quickly ruled out appendicitis, so staff began working on the basis she had gastroenteritis.

But early the next morning, Amrita's mother Satya Tarapureddi raised concerns the girl had chest pain and shortness of breath. 

Amrita underwent an electrocardiogram (ECG) half an hour later at 3.30am, which came back abnormal and led the emergency department registrar Patrick Tan to suspect she had myocarditis.

He consulted with another colleague who agreed with his preliminary diagnosis.

But neither doctor seemed to appreciate the severity of Amrita's condition, the coroner said.

Amrita's blood pressure was not measured at that time but other testing showed elevated lactate, which signified she was deteriorating.

Despite this, Dr Tan determined she did not look unwell and he did not attend to her again until 5.30am, when it was clear her condition had worsened.

Her care was escalated to senior clinicians and specialist units but she suffered a brief cardiac arrest at 7.30am.

Staff organised emergency transfer to the Royal Children's Hospital and a crew arrived about 8.51am, by which time Amrita had gone into prolonged cardiac arrest.

Despite efforts at CPR, she could not be saved. 

In a 2024 inquest into Amrita's death, Monash Health admitted staff had failed to appreciate the seriousness of the young girl's condition.

On Wednesday, Ms Spanos determined Amrita's death was preventable. 

"Certainly by about (4am), when the ECG had been completed and the elevated lactate was available, Amrita's life could have been saved," the coroner said in her findings.

Ms Spanos was also critical of Dr Tan's actions as the emergency department registrar. 

"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," the coroner said.

"(His actions) thereby caused or contributed to her death."

The coroner did not make any formal recommendations, instead commending Monash Health for undertaking an internal review following Amrita's death.

Ms Spanos acknowledged the hospital had implemented a series of changes as a result, including requiring emergency department clinicians to notify on-call consultants in specific cases.

The coroner, who at times appeared to hold back tears while reading her findings, offered her condolences to Amrita's parents seated in the courtroom.

The couple did not speak to media as they left court.