The death of an eight-year-old girl could have been prevented, a coroner has found, after criticising the response of a doctor at a Melbourne emergency department.
Amrita Varshini Lanka’s parents nodded through tears as Victoria’s Deputy State Coroner Paresa Spanos delivered her findings on Wednesday.
Amrita died at Monash Medical Centre’s paediatric emergency department on April 30, 2022, after suffering lymphocytic myocarditis — an inflammation of the heart muscle.
She had arrived at the emergency department at about 1pm the previous day after experiencing two days of abdominal pain, nausea and vomiting.
Initial tests ruled out appendicitis, and doctors proceeded on the assumption that she had gastroenteritis.
However, in the early hours of the following morning, Amrita’s mother, Satya Tarapureddi, told staff her daughter was suffering chest pain and struggling to breathe.
An electrocardiogram was performed at about 3.30am, roughly 30 minutes later. The abnormal result prompted emergency department registrar Patrick Tan to suspect myocarditis.
A colleague consulted by Dr Tan agreed with that initial assessment.
A coroner has found the death of Melbourne schoolgirl Amrita Varshini Lanka could have been prevented.
Amrita’s parents, Chandra Sekhar Lanka and Satya Tarapureddi, struggled to contain their emotions during Wednesday’s inquest findings.
But Coroner Spanos said neither doctor appeared to recognise how seriously ill Amrita was.
Her blood pressure was not checked at that point, while other test results showed an elevated lactate level — a warning sign that her condition was deteriorating.
Despite those indicators, Dr Tan concluded that Amrita did not appear seriously unwell and did not review her again until about 5.30am, when her health had clearly declined.
Her treatment was then escalated to senior doctors and specialist teams, but she suffered a brief cardiac arrest at approximately 7.30am.
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An urgent transfer to the Royal Children’s Hospital was arranged. The retrieval team arrived at around 8.51am, by which time Amrita had entered a prolonged cardiac arrest.
Despite continued resuscitation attempts, doctors were unable to save her.
During an inquest held in 2024, Monash Health acknowledged that staff had failed to understand the seriousness of the child’s condition.
On Wednesday, Ms Spanos formally ruled that Amrita’s death was preventable.
Amrita died from lymphocytic myocarditis, an inflammation of the heart muscle, at Monash Medical Centre’s paediatric emergency department on April 30, 2022.
Chandra Sekhar Lanka and Satya Tarapureddi have spent the past four years seeking answers and justice for their daughter.
‘Certainly by about (4am), when the ECG had been completed and the elevated lactate was available, Amrita’s life could have been saved,’ the coroner said in her findings.
Ms Spanos was also critical of Dr Tan’s actions as the emergency department registrar.
‘While I accept that EDs are busy places and Dr Tan was a relatively junior doctor with many responsibilities, the clinical management and care he provided to Amrita was wanting,’ the coroner said.
‘(His actions) thereby caused or contributed to her death.’
The coroner did not make any formal recommendations, instead commending Monash Health for undertaking an internal review following Amrita’s death.
Ms Spanos acknowledged the hospital had implemented a series of changes as a result, including requiring emergency department clinicians to notify on-call consultants in specific cases.
The coroner, who at times appeared to hold back tears while reading her findings, offered her condolences to Amrita’s parents seated in the courtroom.
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