An Australian coronial investigation has identified missed warning signs in the treatment of the young girl, raising questions about the medical care she received before her death
An eight-year-old Indian-origin girl, Amrita Varshini Lanka, died from myocarditis at a Melbourne hospital in 2022 after medical warning signs were not acted upon promptly. A Victorian coroner has now ruled that her death was preventable, identifying shortcomings in her clinical care and delays in escalating treatment.
Deputy State Coroner Paresa Spanos delivered the findings following an investigation into Amrita’s death at Monash Medical Centre on April 30, 2022. The coroner found that the care provided by the overnight emergency department registrar, Patrick Tan, contributed to the child’s death.
Amrita had been admitted on April 29 after experiencing nausea, vomiting, diarrhoea and abdominal pain for two days. Doctors initially suspected gastroenteritis after tests ruled out appendicitis.
However, her condition deteriorated overnight. Her mother raised concerns about breathing difficulties and chest pain, prompting further medical assessment.
An electrocardiogram conducted at around 3.30 am on April 30 produced abnormal results. Dr Tan suspected myocarditis, an inflammation of the heart muscle, but did not fully appreciate the seriousness of Amrita’s condition, the inquest heard.
Blood tests also indicated deterioration, including elevated lactate levels. The coroner found that these warning signs should have prompted more urgent intervention.
Amrita’s condition worsened in the early hours of the morning. She was subsequently moved to a more critical-care setting and suffered three cardiac arrests. She died less than 24 hours after arriving at the hospital.
The case also highlights the importance of clear clinical handovers, timely interpretation of test results and rapid access to specialist care when a child’s condition deteriorates unexpectedly
The coroner concluded that timely escalation of treatment and an earlier transfer to the Royal Children’s Hospital, which has specialist facilities for critically ill children, could have saved her life.
While acknowledging that emergency departments operate under considerable pressure and that Dr Tan was a relatively junior doctor, Spanos criticised the clinical management provided to Amrita.
The investigation also identified missed opportunities to recognise the severity of her illness and respond appropriately to the test results.
Monash Health, the organisation responsible for the hospital, said it would carefully consider the findings. It added that changes had been introduced since Amrita’s death to strengthen patient monitoring, escalation of care and communication among medical staff.
The findings bring renewed attention to the importance of responding promptly to deteriorating symptoms in children and ensuring that parental concerns receive appropriate medical assessment.
Amrita’s death prompted years of anguish for her family, who sought answers about whether earlier intervention could have prevented the tragedy.
