Coronial finding · Coroners Court of Victoria
On 14 October 2026 Deputy State Coroner Paresa Antoniadis Spanos found that the death of eight-year-old Amrita Varshini Lanka in the paediatric emergency department at Monash Medical Centre on 30 April 2022 was preventable.
- Court
- Coroners Court of Victoria
- Reference
- COR 2022 002305
- Finding delivered
- 14 October 2026 (amended 15 October 2026)
- Cause of death
- Lymphocytic myocarditis
Background
Amrita was brought to the Monash Medical Centre emergency department on 29 April 2022 with abdominal pain, fever and vomiting. She was assessed and treated for gastroenteritis. Overnight her mother raised concerns about chest discomfort and laboured breathing. An ECG and blood tests in the early hours of 30 April were abnormal. Her care was escalated to cardiology and the paediatric intensive care unit from about 0600 hours, after she became hypotensive. She suffered cardiac arrests later that morning and died at 1046 hours, shortly after the PIPER retrieval team arrived.
The inquest was held from 26 to 30 August 2024. Its scope included whether the diagnosis could have been made earlier, delays in escalation and in referral to PIPER, whether the death was preventable, how parental concerns were escalated, and whether staffing, resourcing or competing demands were a factor.
The Coroner's findings
Among other things, the Coroner found that:
- Amrita’s initial management in the emergency department on the day and afternoon shifts was reasonable.
- The overnight emergency registrar had been handed over about 18 patients and held the clinician-in-charge role for the department. His decision not to review Amrita until about 0300 hours was reasonable, as was his initial response to her mother’s concerns. He considered the correct diagnosis and ordered the appropriate tests.
- His dismissal of an elevated lactate result at 0352 hours as spurious, without a prompt repeat test, was unreasonable. As both Monash Health and the registrar conceded, by about 0400 hours the ECG and lactate together required immediate escalation to cardiology and intensive care, which did not occur.
- The troponin result, which was grossly elevated, was not available until about 0528 hours, partly because the registrar did not know that “add-on” tests took longer than fresh requests.
- A low blood pressure reading at about 0600 hours should have triggered a medical emergency team call.
- The phone consultation between the registrar and the on-call paediatric cardiologist at about 0640 hours was deficient on both sides. The information the registrar gave was incomplete and did not convey the severity of Amrita’s condition. The cardiologist did not ask about her blood pressure and lactate, and conceded he should have, or ask to see the ECG. The Coroner described it as a missed opportunity.
- Her mother’s actions reflected a failure of the hospital’s parent and carer escalation processes at the time, and Amrita was placed in an un-nursed cubicle for longer than appropriate.
- Engagement of the PIPER retrieval team was not as seamless as it could have been, but did not cause or contribute to her death.
Preventability
The Coroner found that the weight of expert evidence supported a finding that Amrita’s death was preventable. She found a consensus that by about 0400 hours, Amrita’s life could have been saved through timely escalation to intensive care and paediatric cardiology at Monash Health and involvement of the PIPER retrieval service for transfer to the Royal Children’s Hospital.
The Coroner accepted that emergency departments are busy places and that the registrar was a relatively junior doctor with many responsibilities. She found that the care he provided was nonetheless wanting, and caused or contributed to Amrita’s death.
Comments
The Coroner made no formal recommendations. She commended Monash Health for a comprehensive internal review, including a sentinel event review with 14 recommendations, which she said largely obviated the need for them.
She noted that the Royal Children’s Hospital is the only Victorian health service able to cannulate children of all ages for ECMO, and that, unlike the service for adults, there is no standing emergency paediatric ECMO retrieval service. She said it was imperative that Monash Health and the Royal Children’s Hospital have well-established processes so that requests for assistance are as timely and effective as possible.
Source: Finding into death with inquest: Amrita Varshini Lanka, COR 2022 002305, Coroners Court of Victoria, 14 October 2026 (amended 15 October 2026), accessed 20 October 2026.
