Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

Contributing factors

• delayed recognition of sepsis
• inadequate nursing staffing
• junior staff without adequate supervision
• physical triage area design preventing hands-on assessment
• failure to escalate care despite parental concern
• incomplete clinical documentation
• failure to complete sepsis screening tool (PARROT chart) in timely manner
• junior nurse called away from waiting room before completing care plan
• junior doctor performed only focused assessment without holistic evaluation
• lack of clear escalation pathway for parents
• staff fatigue and competing demands
• lack of vital signs taken at triage

Coroner's recommendations

1. Department of Health/CAHS commit to early implementation of nurse/midwife-to-patient ratios (replacing NHpPD model) in WA public hospitals, with priority for emergency departments. Minimum ratio should match Victorian paediatric ED standards (1:3) and should be actioned without waiting for industrial agreement registration given Department of Health's own Independent Inquiry supports such change.
2. CAHS prioritise implementation and staffing of a supernumerary resuscitation team in the ED at PCH.
3. WA Government consider introduction of 'safe harbour' provisions to protect nurses from AHPRA investigation when adverse events occur in circumstances where known workplace risks have been identified and not rectified by employer.
4. State Government prioritise funding the Department of Health's EMR (Electronic Medical Record) Program to ensure all public hospitals, particularly PCH, have digital tools that make it easier to record information, access records and support clinical assessments. This will enhance patient safety.
5. CAHS implement procedure for observations to be taken at triage or within 30 minutes by waiting room nurse when children present with gastrointestinal symptoms, to provide early benchmark for monitoring sepsis signs.