Aishwarya Aswath’s family releases a report into her death, revealing she had a temperature of 38.8 degrees Celsius and was “floppy” as a “cascade of missed opportunities” left her waiting for care at Perth Children’s Hospital.

The family of seven-year-old Aishwarya Aswath has publicly released a report into her death, revealing she had a temperature of 38.8 degrees Celsius and was “floppy” as she awaited care at Perth Children’s Hospital’s emergency department.
Key points:

• Aishwarya Aswath died after waiting around two hours to be treated
• The report found staff did not correctly identify the signs of her sepsis
• Her family is unhappy with the report and says more answers are needed

In a damning assessment, the report, which was partly tabled in Parliament last week, stated there were failures to address the concerns of Aishwaryas parents on their daughters deteriorating condition, and there was an overall uncoordinated plan of care for her.  
The report detailed what happened the night Aishwarya died, including the response from staff, as she waited around two hours to be treated before being declared dead just after 9:00pm on Saturday April 3.
The panel found there were a cascade of missed opportunities to address parental concerns and incomplete assessments, with a delay in escalation which may have contributed to the patients outcome, the report found.
It revealed a nurse noted the parents were “anxious and concerned about their daughter”, but nonetheless the “parental concern” was considered “absent” by staff, resulting in a score of zero for this criteria.
Aishwarya Aswath was suffering from sepsis when she died.(Supplied: Family
)
That was despite it being documented the mother was “anxious ++”.
The report outlined that if a patient had a temperature higher than 38C, they should be considered for sepsis, but Aishwarya was not.
Instead, at one point a staff member noted Aishwarya’s temperature of 38.2C was a “normal finding”.
At its highest before she was seen by a doctor outside the waiting room, her temperature was recorded at 38.8C.
At 5.52pm, 20 minutes after presenting at the hospital, Aishwarya’s respiratory rate was 44 breaths per minute, her heart rate was 150 beats per minute and she had a blood pressure reading of 114/103.
Sepsis was subsequently identified after her death.
Report ‘contradictory’, Aishwarya’s family say
The document also described Aishwarya as being “alert”, “clingy” and “grunting in pain”, but in a follow-up statement, the nurse said this may not have been the most appropriate word.
Speaking on behalf of her family, Suresh Rajan, said her parents wanted to correct the information in the report as it was “completely contradictory”.
Family spokesman Suresh Rajan says questions remain unanswered about the girl’s death.(ABC News: James Carmody
)
“[This] is why we’ve been saying right from the very start,” he said.
“We didn’t agree with what the findings were, we didn’t agree with the timeline and therefore an external inquiry is going to be the only way that that will be resolved.”
The report was given to the family last week as the government revealed the report’s 11 recommendations in State Parliament.
The report identified seven contributing factors to Aishwarya’s death, including communication issues between staff and between staff and her parents.
It also identified a “lack of recognition of persistent and significant parental concerns as a significant clinical concern to be escalated resulted in a delay in treatment which may have contributed to the patient’s outcome”.
Staff training and skills were also highlighted as an issue because there was a “failure to identify an abnormal temperature against a clearly defined prompt”.
Two of the registered nurses handling Aishwarya were relatively junior, with three and four years of postgraduate experience.
Medical officers, nurse missing
The report revealed three resident medical officers in the emergency department called in sick and none were replaced because of a lack of available staff.
The department was also one nurse down, resulting in medical assessment delays and prolonged waiting times.
The report says senior clinicians had raised “substantial concerns around patient safety” at the hospital.(ABC News: Andrew O’Connor
)
The average wait time was 108 minutes, according to the report.
A shortage of beds, rooms and resources was also shown to be a problem.
The report revealed senior clinicians had escalated “substantial concerns around patient safety” to senior management since October 2020.
It also noted a culture which saw escalation as “futile and ineffective” leading to a failure to call for assistance when it became busier.
‘Unbearably hard to read’: Minister
Health Minister Roger Cook said the report was incredibly distressing.
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“It is unbearably hard to read and it raises more questions than answers,” Mr Cook said.
“But can I please urge a level of caution as the next stage of the inquiries into Aishwarya’s death takes place.”
He added it was not the role of the public to be the “judge and jury” of nurses and doctors referred to in the report, and rather an external inquiry and a coronial inquest would further scrutinise what happened.
The chief executive of WA’s Child and Adolescent Health Service, Aresh Anwar, said he agreed with Aishwarya’s family that she was not shown compassion and care.
He said the family’s feedback had been hard to hear.
But he agreed with them that staff did not correctly identify the signs of her sepsis, despite her parents asking for help five times and not being given that help.
“I do agree with them when they say we showed them no compassion,” Dr Anwar said.
“I agree with them we didn’t appear to demonstrate care.”
Dr Anwar said some of the staff were no longer working in the emergency department but said it was too personal to reveal how many people that involved.
He said he could not explain why the vital signs of the young girl were not acted on sooner or why the parental concern was marked as zero.
He agreed the report raised more questions than answers, but stressed it only provided part of the story and the root cause analysis was only an element of the process.
Timeline of events
The SAC1 Clinical Incident Investigation Report into Aishwarya Aswath’s presentation at Perth Children’s Hospital revealed what happened in the hours before her death:

• 5:32pm: Aishwarya’s father carries her into the Emergency Department
• 5:33pm: Triage nurse interviews her parents. Her mother reports Aishwarya had gastro and has cold hands. Aishwarya tells the nurse she has a headache.
• 5:41pm: Aishwarya’s mother approaches the clerk to report her child’s eyes were discoloured. The registrar checks her eyes and notes discolouration of the irises but not the sclera, spending around 20 seconds with her.
• 5:42pm: Aishwarya’s mother approaches the clerk again, who goes to report to a Registered Nurse (RN1).
• 5:43pm: Aishwarya’s mother approaches the counter again and speaks to a second clerk.
• 5:46pm: Her mother approaches the clerk again and hands over a Medicare card.
• 5:52pm: Aishwarya is seen by RN1 and a Senior Nurse in the waiting area. They find her temperature is 38.8 degrees Celsius, breathing rate 44 breaths a minute and heart rate 150 beats per minute. They note there is no parental concern, recording it on the PARROT chart.
• 6:10pmto 6:40 pm: RN1 is called away to the resuscitation area, as the nurse usually allocated to a particular role in this area is unwell.
• 6:42pm: Aishwarya’s father picks her up and puts her back down on the seat in the waiting area, she appears “floppy”.
• 6:45pm: RN1 returns and hands over the treatment plan to another Registered Nurse (RN2). Recommended treatment is ibuprofen and fluid by mouth.
• 7:06pm: RN2 comes back to administer ibuprofen. The report notes Aishwarya’s hands appear “floppy”. RN2 does not touch Aishwarya at this time.
• 7:09pm: RN2 returns with an ED consultant (ED1). The consultant speaks with the parents.They are moved to POD B, a cubicle.
• 7:11pm: RN2 leaves the cubicle.
• 7:14pm: A third nurse (RN3) enters the cubicle where they reportedly examined Aishwarya. She moves Aishwarya to the resuscitation area.
• 7:25pm: Aishwarya is put on an IV. Her temperature is now 39.8 degrees.
• 8:21pm: CPR is commenced. 
• 9:04pm: CPR ceases.