Brief
Coroner says delayed response contributed to eight‑year‑old’s death at Monash Children’s Hospital
Deputy state coroner Paresa Spanos said the child’s death could have been avoided if early test results had been acted on.
By Felo News Desk · Published
Victoria’s deputy state coroner Paresa Spanos ruled on Wednesday that the death of eight‑year‑old Amrita Varshini Lanka was preventable, citing a delayed response by a Monash Children’s Hospital emergency‑department doctor.
What happened
Amrita Lanka was admitted to Monash Children’s Hospital on 29 April 2022 after two days of stomach pain, nausea and vomiting. Initial tests ruled out appendicitis and staff treated her for gastroenteritis. Early on 30 April, her mother reported chest pain and shortness of breath. An electrocardiogram performed at 3:30 am showed abnormal results, leading registrar Patrick Tan to suspect myocarditis. Despite elevated lactate indicating deterioration, Tan did not reassess the child until 5:30 am. Her condition worsened, a brief cardiac arrest occurred at 7:30 am, and she was transferred to the Royal Children’s Hospital at 8:51 am, by which time she was in prolonged cardiac arrest and could not be revived.
What the reports add
The coroner’s findings note that blood pressure was not measured at the time of the ECG, and that staff failed to appreciate the seriousness of the abnormal test results. A 2024 inquest had already identified staff’s failure to recognise the severity of her condition.
What was said
Spanos said, “When the ECG had been completed and the elevated lactate was available [at about 4 am], Amrita’s life could have been saved,” as reported by the Sydney Morning Herald.
How it came about
Amrita’s death prompted a 2024 inquest in which Monash Health admitted staff had not fully understood the seriousness of her illness. The recent coroner’s report builds on that earlier inquiry, reinforcing calls for clearer protocols in paediatric emergency care.
Key facts
- Amrita Lanka died on 30 April 2022 at Monash Children’s Hospital. (smh.com.au)
- An ECG at 3:30 am showed abnormal results suggesting myocarditis. (smh.com.au)
- Deputy state coroner Paresa Spanos ruled the death preventable. (smh.com.au)
- The coroner said earlier action on the ECG and lactate could have saved her life. (smh.com.au)
Sources
- [1] smh.com.au — originally reported as “Monash Children’s Hospital doctor contributed to eight-year-old Amrita Lanka’s death, court hears”
