Junior doctor's care contributed to death of Melbourne girl Amrita Lanka, coroner finds

A Victorian coroner has found that the actions of a junior doctor in a busy emergency department contributed to the death of an eight-year-old girl, Amrita Lanka, whose life could have been saved.

Amrita died from myocarditis in 2022 after arriving at the paediatric emergency department of Monash Medical Centre in Melbourne's south-east.

Events leading up to Amrita's death

Deputy State Coroner Paresa Spanos found Amrita's death was preventable and that the doctor in charge, Patrick Tan, did not appreciate the severity of the girl's symptoms in the early hours of April 30 that year.

"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 … and thereby caused or contributed to her death," Magistrate Spanos said.

Amrita was referred to the emergency department on April 29, 2022, by her family doctor after two days of nausea, vomiting, diarrhoea, and abdominal pain.

Magistrate Spanos said Amrita was alert and that her vital signs were in the normal range when she was triaged shortly before 1pm.

Less than 24 hours later, Amrita was dead.

Magistrate Spanos said doctors made a working diagnosis of gastroenteritis.

The girl was placed in a cubicle that did not have an allocated nurse.

Later that night, Amrita's mother said her daughter experienced "hard breathing".

"She told me, 'Mama, hard breathing, hard breathing'. Then immediately I pressed the staff assistance button but nobody came," Ms Tarapureddi said.

"If they had put more attention to her, maybe today my Amrita could be sitting next to me."

Life-saving opportunities missed, coroner finds

The court heard that Dr Tan, the overnight registrar, conducted a review at about 3:20am on April 30.

An electrocardiogram test returned abnormal results, the court heard.

Dr Tan suspected Amrita was suffering from myocarditis, but told the inquest he did not appreciate the severity of her condition.

Dr Tan, who was 12 weeks into his first paediatric rotation, said he was in charge of about 18 patients during his shift.

Further blood tests were ordered but no-one properly attended to Amrita until about 5:30am.

A troponin test, which measures heart muscle damage, came back at more than 27,000 nanograms per litre.

The normal level is below 10, the coroner said.

Amrita was transferred to the acute section of the emergency department and suffered three cardiac arrests, the last shortly after a retrieval team from the Royal Children's Hospital arrived.

"the die was already cast"

Magistrate Spanos said Amrita's life could have been saved with "timely escalation" and an earlier transfer to the RCH, which had specialised life support services for children with critical heart and lung conditions.

Other missed opportunities for doctors included high lactate levels detected in a blood test and a low blood-pressure reading that should have triggered a medical emergency call.

Monash Health had made changes to practices and policies and improved staff education, the coroner said.

Monash Health conducted its own review in 2022 and admitted failings in the lead-up to Amrita's death.

Monash Health agreed to implement 11 recommendations to improve patient care following a review conducted after Amrita Lanka's death.

In a statement, Monash Health said it would carefully consider the coroner's findings.

"Since Amrita's death, Monash Health has made changes to strengthen patient monitoring, escalation of care and communication, and we remain committed to learning and improving patient safety," it said.