Coroner Finds Melbourne Girl's Death Preventable Due to Missed Warning Signs
Victoria's deputy state coroner criticizes hospital staff for failing to recognize the severity of an eight-year-old's deteriorating condition.
An eight-year-old girl's death from lymphocytic myocarditis was preventable, Victoria's deputy state coroner Paresa Spanos has found, citing missed warning signs and a hospital doctor's inadequate response.
Amrita Varshini Lanka died in the paediatric emergency department of Monash Medical Centre on April 30, 2022, after presenting with stomach pain, nausea, and vomiting. Initially treated for gastroenteritis, her condition worsened, and her mother raised concerns about chest pain and shortness of breath.
An electrocardiogram (ECG) performed early on April 30 showed abnormalities, leading an emergency department registrar, Dr. Patrick Tan, to suspect myocarditis. While a colleague agreed with the preliminary diagnosis, the coroner noted that neither doctor appeared to grasp the severity of Amrita's condition. Her blood pressure was not taken at this critical juncture, despite other tests indicating deterioration, such as elevated lactate levels.
Dr. Tan did not reassess Amrita until 5:30 a.m., by which time her condition had significantly worsened. Her care was escalated to senior clinicians and specialist units, but she suffered a cardiac arrest at 7:30 a.m. Efforts to transfer her to the Royal Children's Hospital were initiated, but she went into prolonged cardiac arrest before the crew arrived, and resuscitation efforts were unsuccessful.
In a 2024 inquest, Monash Health acknowledged that staff had failed to appreciate the seriousness of the young girl's condition. Spanos stated that Amrita's life could have been saved by approximately 4 a.m. on April 30, when the ECG results and elevated lactate levels were available.
The coroner was critical of Dr. Tan's clinical management and care, stating it was "wanting" and "thereby caused or contributed to her death." Spanos acknowledged the demands on emergency departments and the junior doctor's responsibilities but emphasized the need for appropriate care.
Monash Health has since implemented changes, including requiring emergency department clinicians to notify on-call consultants in specific cases. The coroner offered condolences to Amrita's parents, Chandra Sekhar Lanka and Satya Tarapureddi, who have been advocating for justice over the past four years.
