A coroner in Melbourne has ruled the death of an eight-year-old girl from myocarditis was preventable, criticising delays in recognising the severity of her condition. 

The Coroner’s Court of Victoria in Melbourne has criticised the parent and carer escalation processes in place at Monash Medical Centre in the city and deemed the death of a young girl from lymphocytic myocarditis at the end of April 2022 as preventable. 

The eight-year-old had been presented to the Paediatric Emergency Department by the family GP who suspected appendicitis. She was triaged shortly before 1300 when she was alert, and her vital signs were within normal ranges.

At about 1500, she was medically reviewed for the first time by an emergency department registrar who arranged an abdominal ultrasound and blood tests. The ultrasound was performed in the late afternoon, and a surgical review took place at about 1900. 

At that time, the diagnosis of appendicitis was determined to be unlikely, and given her overall presentation, the working diagnosis was gastroenteritis.

At about 0300 hours on 30 April, the overnight emergency department registrar raised concerns about the girl’s shortness of breath and chest pain. He consulted with his colleagues, however, neither doctor appears to have appreciated the extent of the abnormality shown on the ECG which had been performed, and the severity of the girl’s condition.

From about 0600 hours, the registrar escalated her care to a range of senior clinicians and specialist units, including the Paediatric Intensive Care Unit (PICU) and the on-call cardiology consultant. In the meantime, her condition continued to deteriorate. At 0730 hours, she suffered a brief cardiac arrest with a return of spontaneous circulation after two minutes of cardiopulmonary resuscitation.

At about 0740 hours, the ICU registrar suggested that the emergency department registrar contact the Paediatric and Infant Perinatal Emergency Retrieval (PIPER) service at the Royal Children’s Hospital. 

The PIPER retrieval team arrived at 0851. Unfortunately, shortly after their arrival, the girl went into prolonged cardiac arrest and could not be saved despite over 45 minutes of cardiopulmonary resuscitation, and she was pronounced deceased at 1046. 

Consensus in the evidence 

In its report, the coroner concluded that there is a consensus in the evidence that certainly by about 0400 hours, when the ECG had been completed and the elevated lactate was available, the girl’s life could have been saved with timely escalation to PICU and paediatric cardiology at Monash Health, and involvement of the PIPER retrieval service to transfer her to the Royal Children’s Hospital for further management.

“The clinical management and care [the doctor] provided to Amrita was wanting,” the report said. 

The coroner highlighted that Monash Health has undertaken an internal review into the girl’s death and made several changes aimed at addressing the issues that arose with the clinical management and care provided to her.

“Monash accepts that there was a failure by it to appreciate the rapidly progressive nature of this condition and the need for timely treatment,” the hospital said. 

“Since [her] passing, Monash Health has reviewed her presentation to the Emergency Department carefully and developed and implemented recommendations to educate, support and assist its staff in the early recognition of this extremely rare but devastating illness,” it added.