‘Deep sense of disbelief’: Aishwarya Aswath inquest reveals shocking failures

The ongoing coronial inquest into the death of seven year old Aishwarya Aswath finds systematic failures in emergency response procedures.

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It is currently day four of the eight-day inquest into the death of Aishwarya Aswath at Perth Children’s Hospital.

Last year, on 3 April, seven-year-old Aishwarya died in the resuscitation room after waiting almost 2 hours with her parents in the waiting room with worsening sepsis that led to multiorgan failure. Following her death, an inquiry was conducted in November 2021 by the Australian Commission on Safety and Quality in Health Care, where 30 recommendations were made.

The ABC has reported that the recommendations related to the following: “recognising parental input, improving the nurse and medical workforce, improving the layout of the hospital’s emergency department, and better understanding CALD patients and their families.’’

Concerns from the inquiry included issues with the triage staffing and nursing staff in general, an increase in emergency department (ED) admissions from more respiratory illnesses and mental health patients during COVID, rostering challenges, insufficient parental communication, and a challenge in sepsis recognition and management.

In the November inquiry, Aishwarya’s parents Aswath Chavittupara and Prasitha Sasidharan indicated that they had ‘a loss of trust in the hospital’ and believed that ‘some of the information it provided was incorrect.’

The new internal inquest began on Wednesday, 24 August and will end on Friday, 2 September.

It has been reviewing the incident, including individual statements and CCTV of staff that were involved in Aishwarya’s care that night.


On day one of the inquest, Aishwarya’s mother Prasitha gave a statement to the Perth Coroner’s court where she recalled that in the waiting room, she had approached staff five times, pleading with them to assess her daughter.

The issue of understaffing was also raised. Dr Anwar, chief executive of the WA Child and Adolescent Health Services, stated that specialist paediatric nurses were traditionally called from overseas, but due to an increase of demand for medical facilities and closed borders during the pandemic, there was no longer enough staff.

Another key issue was brought forth on the second day of the inquest, where Aishwarya’s triage score was assessed. This score is used to scope of the severity of illness and therefore, the urgency of care needed. She was given a score of four (where one is the most urgent), which is defined as ‘people who need to have treatment within one hour, with a potentially serious condition’.

CCTV showed that the triage nurse, Ms Jacqueline Taylor, did not perform a hands-on assessment of Aishwarya as it was standard practice during time pressure, and there was no equipment in the triage area to perform temperature and respiratory checks.

The next doctor that saw her did not have time to check the triage notes and was not aware of her parents’ other concerns and reported symptoms, so assumed it was a gastrointestinal issue.

On the third day of the inquiry, the court heard from junior nurse, Tahnee Vining. She stated that there was a failure in the machine that read her blood oxygen concentration. Later, when Aishwarya was rushed to the resuscitation room, a blood gas analysis machine failed and Ms Vining was sent three levels up to obtain another machine, which took upwards of 15 minutes.

Since Aishwarya’s death last year, two other South Asian Australian children have died in a similar situation — of medical staff brushing off parents’ concerns. On 30 April, eight-year-old Amrita Varshini Lanka died at the Monash Children’s hospital in Melbourne after staff did not listen to her mother’s pleas for urgent care until she was in critical condition.

In May, five-year-old Hiyaan Kapil died just hours after he was discharged when his father pushed to keep him at the Logan hospital in Brisbane.

More evidence will be heard in court over the next four days, where South Asian and other CALD communities who have been moved by the tragic death, are eagerly awaiting information to push for systematic reform.

READ MORE: ‘Prioritise migrant well-being’: experts on high COVID-19 death rate among ethnic minorities 

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