The waiting room nurse was called away for almost an hour and two pieces of medical equipment failed as a seven-year-old child lay quietly dying of sepsis while waiting to be seen in Western Australia’s flagship children’s hospital, a coronial inquest has been told.
- Machines being used to assess Aishwarya failed, the inquest heard
- The emergency department was short-staffed on the night
- At least 20 other patients were waiting to be seen
Aishwarya Aswath died on the night of April 3 last year after waiting almost two hours to be seen by a doctor at the Perth Children’s Hospital.
The inquest, which on Friday entered day three, is investigating how trained professionals missed the warning signs and why her parents’ concerns were not acted on at an earlier stage.
The waiting room nurse working that night, Tahnee Vining, gave evidence that while she and a trainee nurse shadowing her that night assessed Aishwarya in the triage area, a machine to read her blood oxygen concentration failed.
She said this was a common occurrence and “still happening today”.
The trainee nurse went to get another machine which Ms Vining said did work and could establish her levels were normal.
But the court also heard that later that night, while doctors were desperately trying to revive Aishwarya, a blood gas analysis machine failed, and Ms Vining had to go up three storeys to use one in another department, taking her away from the resuscitation area for 10 to 15 minutes.
Ms Vining also gave evidence that if she had been able to stay in the waiting room instead of having to assist in other areas of the ED, she would have noticed Aishwarya’s decline.
“I think if I had have been present in the waiting room … I would have been able to finish her assessment I would have been able to recognise her deterioration and the severity of her illness,” Ms Vining said.
On that night, Ms Vining was also expected to fill other roles including resuscitation runner.
She was also filling an informal role known as a “floater nurse” where she could be called at any time into other sections of the ED to assist doctors.
Nurse’s attention diverted
A few moments after she sat down to enter information about Aishwarya’s vital signs into the system, she was asked to attend another section of the ED to draw blood from a patient.
While there, a high-priority case came into the resuscitation area and she was required to respond.
Ms Vining said as a junior nurse, she didn’t think she could say no.
“As a junior nurse when I first started I would not say no to anyone, I feel there was a lot of pressure to keep going and keep going,” she said.
The court heard that since Aishwarya’s death, three nurses had been assigned to the waiting room, and they could not be allocated to other areas of the ED.
By the time she returned to the waiting room to record her notes at about 6:50pm, it was time for her to go on break and hand over to another nurse.
She gave her handover and verbally communicated her plan for Aishwarya, which was to observe her after providing oral fluids and try to reduce her fever with medication, then completed up to four different sets of notes that were required.
She gave evidence the ED was busy that night and there were around 20 patients awaiting care when she assessed Aishwarya.
‘I did the best I could’
Ms Vining was also grilled about why she didn’t refer up to a more senior nurse when Aishwarya recorded a temperature above 38.5 degrees Celsius, which according to guidelines meant she should have considered sepsis.
She said high temperatures were common.
“We were short-staffed, there was no one to escalate to, there were no senior staff. I did the best I could with what I had,” Ms Vining said.
She said she had not been able to access policy documents relating to an observation tool called the PARROT (Paediatric Acute Recognition and Response Observation Tool) chart.
She said she scored parental concern on this chart as “zero” because she believed she had allayed Aishwarya’s parents’ concerns.
At one point in her evidence she broke down in tears, saying she was overcome with what happened, and how sorry she was for Aishwarya’s family.
Parents don’t blame staff
Family spokesman Suresh Rajan said outside court that the parents did not blame individual staff working that night.
“When you look at all the evidence … it is absolutely certain that there are staffing issues at play,” Mr Rajan said.
“The parents have been very clear from the start, it is not an issue of scapegoating anyone, it is absolutely the system that needs to be addressed,” he said.
“We want to make sure that what we find in the systemic failures that happened they should have been addressed by now.”