By Rachel Eddie
Victorian parents will get help advocating for their sick children in hospital after a report showed an increase in the number of deaths that should have been prevented because doctors ignored parental concerns.
Health Minister Mary-Anne Thomas has apologised to Victorian families after an increasing number of children were injured or died in hospital when they shouldn’t have. The deaths and harms are referred to as “sentinel events” because they come as a result of system and process deficiencies.
Chandra Lanka (left) and Satya Tarapureddi’s daughter Amrita died in hospital last year.Credit: Justin McManus
The state will develop an escalation scheme to help parents advocate for their children in hospital after an annual report from Safer Care Victoria revealed the total number of sentinel events at Victorian hospitals rose from 168 in 2020-21 to 240 the following year. Children were involved in 38 of the 2021-22 incidents.
The proportion of sentinel events affecting children increased to 16 per cent in 2021-22, up from 12 per cent the year prior.
“This is not OK. I’m sorry,” Thomas said on Monday.
The report identified deterioration as the most significant factor contributing to sentinel events among children.
Satya Tarapureddi resorted to asking the cleaners for help at Monash Children’s Hospital last year while daughter Amrita deteriorated. The eight-year-old was struggling to breathe, had chest pain and a high heart rate, but doctors ignored or misinterpreted signs she was critically unwell.
By the time doctors realised, it was too late. Amrita died 21 hours after arriving at the hospital of myocarditis, an inflammation of the heart muscle.
“We are traumatised,” her crying father Chandra Lanka said on Monday.
A Monash Health sentinel event report and the Victorian coroner both found that Amrita should have been transferred to the Royal Children’s Hospital for life support within a window of 2½ hours, which would have improved her chance of survival.
Her parents have spent almost a year lobbying the government for an escalation system they call Amrita’s Rule, and on Monday welcomed news that Victoria would develop a scheme to help parents advocate for their children in hospital.
Amrita Lanka died in hospital aged 8.Credit: Justin McManus
“This is something we have been relentlessly fighting for since the day we lost Amrita,” Lanka said. “We lost her. But in her demise, we are seeing a change in Victorian hospital systems. It is going to make a difference.”
The parents will be part of a working group to design the system, which is already established in some other states. A timeline for its rollout is yet to be confirmed.
“We are working with parents, we want to get it right. But to my mind, it is absolutely imperative that we work to deliver these initiatives as quickly as possible,” Thomas said.
A parent or carer would have the ability to escalate concerns if they feel they are not being acted on.
Satya Tarapureddi says she pleaded for help as her daughter deteriorated in hospital last year.Credit: Justin McManus
Shadow health spokeswoman Georgie Crozier said the annual data about sentinel deaths was long overdue.
“These figures should’ve been made publicly available months ago. Instead of addressing these problems head on, the Andrews government continues to attempt to spin away and cover up their own failings,” Crozier said.
“Victorians deserve a health system they can have confidence in and Labor must act to address this tragic increase in avoidable deaths and serious harm across our health system.”
Liat Watson’s son, Mitchell, spent his final 18 months with a poorer quality of life, unable to use his hands, because of avoidable harm in hospital before he died, aged 7, of a rare genetic disease.
“It was mainly because my concerns at the time weren’t being listened to,” Watson said. “He died 18 months later without ever having been able to use his hands again.”
She said she felt powerless when her concerns were ignored and believes Mitchell would have retained the use of his hands if an advocacy system was in place at the time.
“That made a huge impact on the quality of what was always going to be a shortened life, and I think if I had been able to call somebody else and get their advocacy on board, it would have made an incredible difference. He’d be able to be colouring in colouring books still.”
The number of reported sentinel events at hospitals has risen since Safer Care Victoria was established in 2017. Thomas said she viewed that as positive because it showed increasing transparency.
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