Children’s hospital deaths: What has changed since the Aishwarya Aswath case?

The face of a bright-eyed, smiling child looks out from a newspaper front page. The accompanying headline reads: A Life Cut Short. It was July 22, 2000, and a Perth couple’s lives had been shattered by the incomprehensible death of their 18-month-old daughter as a result of a terrible mistake at Joondalup Health Campus. Julie-Anne Williams, an otherwise happy and healthy toddler, had been taken to the hospital by ambulance after suffering from febrile convulsions and a temperature. She was given an overdose of the anti-seizure drug phenytoin, four times the maximum dose for a toddler, which caused heart failure and brain damage. Julie-Anne was transferred to Princess Margaret Hospital, where her parents David and Natalie made the dreadful decision to switch off her life-support and donate her organs. In the years after losing their little girl, Julie-Anne’s parents lobbied for change in WA hospitals, and in 2001 a coronial inquest found serious lapses in concentration by a doctor and nurse caused her death. The coroner recommended improved guidelines and protocols around the administration of drugs to children. Since then, more than five WA children have died in circumstances that have prompted investigations, and in some cases coronial inquiries, and led to changes in hospital systems. Over the last two decades many more front pages have been dedicated to problems in our health system, from revelations about delays facing children needing cancer treatment, to warnings by doctors of a system in crisis and serious issues with staff morale which saw heads roll in senior management. Whether real change has been implemented to stop more children dying needlessly has come back into the spotlight after Aishwarya Aswath’s death last month. The seven-year-old died of a bacterial infection after Perth Children’s Hospital staff failed to diagnose how sick she was when her parents begged for their daughter to be examined more thoroughly on Easter Saturday. Twenty-one years on from their daughter’s death, Mr and Mrs Williams still live in the Greenwood home where Julie-Anne spent her short life. Her ashes, contained in a teddy bear-shaped urn, sit on a shelf above a painting of the cute, chubby-cheeked toddler. Mr Williams smiles as he remembers Julie-Anne’s final day in the house, standing at the flyscreen and looking out at her dad in the backyard, wanting to join him but kept inside because of her rising temperature. “She was a real character, a little redhead, she had a mind of her own,” he said. The couple and their 17-year-old daughter Maddison, whose arrival four years after Julie-Anne’s death brought some much-needed joy, celebrated what would have been Julie-Anne’s 21st birthday last year with cake and balloons, and she remains “very much part of the family”. The couple belong to a small, tragic club. Its members have experienced the very definition of “every parent’s worst nightmare”, and if not for errors or missed opportunities, their children might still be alive today. There isn’t a day that Mr and Mrs Williams don’t think about their daughter, and when similar cases occur in WA, their trauma feels fresh. The couple have been following the case of Aishwarya Aswath. “It’s heart-wrenching, because all you can hope for is that it’s not going to happen to anyone else,” Mr Williams said. “We’re not going to get Julie-Anne back, but all we hoped for, and the only reason we went to the Coroner’s Court and spoke out as much as we could, was so no one else would go through it.” Samantha Piani felt “sick to her stomach” when she heard about Aishwarya’s death. September will mark 11 years since Ms Piani’s six-year-old son Sebastian Parman died of pneumonia at Geraldton Hospital, three days after he was first seen at the hospital with flu-like symptoms and a rash. It would be another six years of intense lobbying from Ms Piani for answers before a coronial inquest confirmed what she had suspected — that her little boy’s life could have been saved if he had been treated properly. Coroner Barry King found there were “failures at different levels in the care and management”, including delays in diagnosing Sebastian with scarlet fever and failure to recognise that he was septic. “It is possible, if not likely, that he could still have survived at that stage if provided appropriate treatment, but a clinical misjudgment left him without that chance,” Mr King said. A number of improvements were made at the hospital as a result of the inquiry. “Seeing this is bringing up some bad memories,” Ms Piani said. “Hospitals still aren’t listening to parents, this is what I’m seeing,” she said. “I don’t blame the Government, I blame the whole system.” Sebastian’s death came at a time of heightened attention on healthcare in regional WA because of the deaths of four patients, including two children, caused by clinical incidents at Northam Regional Hospital. Andrew Allan, 16, and 12-day-old Lachlan Hughes died within six weeks of each other, and a review by then-chief medical officer Gary Geelhoed, coupled with coronial investigations, led to major change to hospital systems and resulted in three doctors being suspended. As that review was being carried out, cracks were appearing at the ageing Princess Margaret Hospital in Perth. Once a leading paediatric care and research facility at the forefront of medical care, in its final years the century-old hospital was beset with issues and concerns from both staff and parents. An October 2012 front page article in The West Australian, headlined “Kids let down”, chronicled concerns about the unacceptable delays facing children needing cancer treatment. The face of that story, and a subsequent campaign from families and medical staff for more resources, was three-year-old Archie Caldow, who had neuroblastoma, and who was forced to travel with his family to Sydney for cancer treatment because WA’s only paediatric radiation oncologist was on holiday. As more families went public with similar experiences, the head of PMH cancer services made an impassioned plea for resources after the growing realisation her staff were not coping with an unrelenting stream of sick children. Construction had started on the long-awaited $1.2 billion new children’s hospital in Nedlands, but there were already concerns that it was not big enough, prompting the then-Barnett Liberal Government to spend an extra $35 million on 24 new beds, resisting pressure from the Australian Medical Association to add another storey. It would be another six years, following lengthy delays, an asbestos scare and a lead contamination crisis, before Perth Children’s Hospital opened in May 2018, by which point Mark McGowan was Premier. In the meantime, staff morale at the deteriorating PMH was at an all-time low. Professor Geelhoed, also a former head of the PMH ED and past Australian Medical Association president, was commissioned by the Child and Adolescent Health Service board to investigate the extent of staff discontent at PMH and the risk to patients. In June 2017, he published an explosive report which found children’s safety would “almost certainly” be compromised without an immediate change in leadership style or personnel, pinpointing “a fundamental failure of leadership” extending far beyond the delayed move to Perth Children’s Hospital. Feedback from more than 200 staff revealed a culture of fear over speaking out, and in a damning assessment, more than 90 per cent of employees said PMH was a “very unhappy place to work.” An autocratic management had led to emotional trauma among staff, who had ensured the problems had not so far affected patients, but the report warned that was unlikely to last because of a clear link between hospital culture and safety. The report made 21 recommendations, all of which have been implemented, and triggered the departure of the head of Child and Adolescent Health Services, Frank Daly, later followed by PMH’s executive director Michelle Dillon. Questions are again being asked about the state of our health system as the WA community reels from Aishwarya’s death. The tragedy has exposed tensions between hospital management and ED staff, which boiled over this week when more than 1000 doctors, nurses and health workers who rallied outside PCH told of dangerously understaffed and overcrowded emergency departments. Nurses described how they were “scared for the children of Perth” because of chronic staff shortages which prevented them from having time to check vital signs and offer care and compassion to kids and their parents. Health Minister Roger Cook told the crowd the Government was aware the system needed fixing. “We know we need to address the culture. We need to address the relationship, particularly between frontline health workers and executive teams,” he said. “We know that we have to do better.” AMA president Dr Andrew Miller believes the relationship between frontline workers and executive teams, and what he says is a flawed governance model for the six boards which oversee WA public hospitals and health services, are at the heart of issues at PCH. “Fundamental fractures and fissures are why you get to this point, and there is a fracture between clinical staff and the executive who work in a command and control fashion, where they are not collaborative,” Dr Miller said. “It is the leadership of the director general (of Health, David Russell-Weisz) and the Health Minister that are critical for setting this culture, which then cascades through the system, and in my view they failed to capitalise on the opportunity from the 2017 report to improve the culture.” He wants to see a “rebalancing of power” between clinicians and the executive. He is pessimistic that the hospital system has improved since the Geelhoed report, or since the previous crises over the past two decades. “I think it’s worse than it was during these crises, I think a lot of senior nurses and doctors with experience have found a way to leave the system, and new people are not realising where the traps lie and getting burnt out within a few years,” he said. Dr Russell-Weisz, who ordered the 2017 review, said morale had come a huge way since then, but there was still work to be done. He said there was naturally raw emotion among staff but he was confident the hospital could recover. “The executive want to listen to (staff) and heal with them … not forgetting the most important people, the (Aswath) family,” he said. In the latest AMA magazine PCH paediatric registrar Jemma Hogan said the new hospital environment had provided a genuine morale boost and better engagement between leadership and staff. She said Aishwarya’s death was felt deeply and she had “never seen a hospital band together to support its staff like PCH has over the past month.” “What’s particular concerning is that it could have easily happened to any of us, at another hospital, at another time of day, in another department,” she wrote. “For many of my colleagues it brought back memories and associated trauma of previous cases with poor outcomes, compounded the constant pressure we are under to never make clinical errors and forced everyone to reflect on the difficulties associated with finite resources in a system stretched beyond capacity.” The author of the 2017 report is also positive about the health system, while warning the outcry over the current crisis could see morale plummet. Professor Geelhoed, who worked at PMH for 40 years, including 22 years as ED director, said the change of leadership and relocating to the new hospital in 2018 had led to a dramatic turnaround in morale under CAHS chief executive Aresh Anwar and board chair Debbie Karasinski. Ms Karasinski stood down this month in the wake of Aishwarya’s death. But Professor Geelhoed feared the outcry over Aishwarya’s death could devastate staff morale and, in turn, lead to poor patient outcomes. He said in his experience, parents who have suffered a loss in such a circumstance will almost always express the view that “I don’t want this to happen to another child, another family”. “An appropriate investigation and recommendations should go some way to achieve this,” he said. “My heart goes out to Aishwarya’s family,” he said. “I also feel for the staff who will be devastated. By all means let’s examine what happened and hopefully make it less likely that this will happen to ‘another child, another family’, but let’s not let unhelpful commentary, grandstanding and premature calls for resignations actually achieve the opposite.” Professor Geelhoed said human error was always going to exist, but hopefully lessons would be learned from the tragedy. Those lessons will come via an independent inquiry, which will focus on the factors which contributed to Aishwarya’s death and the approach to clinical governance, risk and adverse incidents at PCH. The report will be completed within about 10 weeks, and Mr Cook has also pledged an additional 20 beds at PCH. As the community awaits the findings, grieving mother Rhiannon Perry is still waiting for answers on why her month-old daughter, Aria, died last year from a staph infection contracted at King Edward Memorial Hospital when just a week old. “I don’t want to necessarily point my finger at any one person, but someone has to be responsible,” she told The West last month. David Williams understands this need for answers. As he and his wife were on their own quest, they regularly gave talks to graduating nurses, encouraging them to speak up if they felt something was wrong. “The health system was atrocious back then. “I believe it is a lot better now. I certainly hope so.”