The triage nurse who assigned seven-year-old Aishwarya Aswath a low priority rating at Perth Children’s Hospital says if she had more time and resources it could have changed the child’s care.
Key Points:
- Jacqueline Taylor says nurses were under pressure the night Aishwarya died
- He says he only assessed the seven-year-old through a Plexiglas shield
- Aishwarya’s parents left the runway as the video of her last moments was played
Aishwarya died of sepsis after waiting almost two hours in the emergency department at Perth Children’s Hospital for treatment in April last year.
A coronial inquest is investigating how trained professionals missed the warning signs and why their parents’ concerns were not acted upon at an earlier stage.
Her parents, mother Prasitha Sasidharan and father Aswath Chavittupara, attended the court today with a large framed photo of Aishwarya, which they placed outside on one of the chairs in the courtroom.
Hospital stress points
Triage nurse Jacqueline Taylor said court staff had been under pressure last year when Aishwarya walked through the doors of the emergency department.
“The whole department was operating under a lot of pressure, time pressure and exhaustion and a long period of fatigue where we needed more resources,” Ms Taylor said.
Nurse Jacqueline Taylor told the inquest that she assessed Aishwarya from the other side of a Plexiglas screen. (ABC News: Andrew Willesee)
“Having been given time to do a more thorough assessment could have changed the course of his care.”
Ms Taylor gave evidence that on the night of April 3 last year, she assigned Aishwarya a triage assessment score of four, at the lower end of the severity scale.
Do you know more about this story? Contact Rebecca Trigger
It meant that when the family entered the waiting area, they were assigned to Pod C and other patients from another section were prioritized.
Distressing images are shown
Aishwarya’s parents briefly left court when CCTV footage from the triage area was played, with her mother yesterday saying she could not bear to watch the CCTV of her daughter’s final moments.
Nurse Taylor was asked what signs she was looking for and why she came to the conclusion that Aishwarya was suffering from a gastrointestinal problem.
Aishwarya Aswath’s parents brought a large framed photograph of their daughter to the court. (ABC News: Andrew Willasee)
He noticed a history of diarrhea and vomiting, but did not notice that Aishwarya was wearing a diaper.
Nurse Taylor was asked if Aishwarya’s cold hands were indicative of something more serious, but said many children had this symptom.
He said, based on the information presented to him at the time, he believed a triage score of 4 was appropriate.
He was not aware that Aishwarya was experiencing pain all over her body, and if he had known, he might have changed his assessment.
No practical assessment
The CCTV showed Ms Taylor speaking to the family but not touching Aishwarya or carrying out a hands-on assessment, which she accepted was not optimal but was standard practice at the time due to time constraints.
He said there was no equipment in the triage area to perform more rigorous assessments such as temperature and breathing checks.
The nurse who assessed Aishwarya did so through a Plexiglas screen, the inquest found. (ABC News: Keane Bourke)
Also between her and the family was a large perspex screen, which had been installed as a COVID-19 prevention and safety measure for nurses.
The court heard that the size of the triage table had since changed, bringing the nurse closer to the patients.
While I was assessing Aishwarya, two more families arrived, as well as someone who wanted to be let into the waiting room.
Do “three jobs at once”
The court also heard he was responsible for letting patients in and out of the main waiting area and escorting high priority patients.
“You’re really expected to do three jobs at the same time, … triage nurse, concierge and a chaperone role,” family lawyer Tim Hammond told her, to which she agreed.
He told the court there was no specific triage policy for PCH at the time, but he expected to spend two to five minutes with patients.
The doctor just looked at Aishwarya’s eyes
The inquest also heard from the “younger” doctor on duty that night who was asked to look at Aishwarya in Pod C.
Aishwarya’s mother approached an employee at Pod C and told him that she was concerned about the “white spots” in Aishwarya’s eyes.
In a statement of evidence read to the court, this clerk, who has no medical training, said he thought this could be a sign of febrile convulsions.
She says she told Dr Tony Kuok Liang Teo about Ms Sasidharan’s concerns and added her observation of possible febrile seizures, basically seizures that can happen in children, but Dr Teo only heard the concerns about the eyes of Aishwarya.
Dr Teo stressed that when he examined Aishwarya he noticed two discolored spots on her sclera, but there were no signs of febrile seizures.
CCTV showed that Dr Teo spent just 20 seconds with the family and looked into Aishwarya’s eyes as she lay with her head back on her father’s lap.
Dr Tony Kuok Liang Teo arrives at the coronial inquest into Aishwarya Aswath’s death. (ABC News: Andrew Willesee)
The doctor told the court that the emergency department was busier than usual that night and he did not stop to check Aishwarya’s triage notes before going to see her.
He said he was unaware of his parents’ other concerns and reported the symptoms.
He did not touch her and only examined her eyes, before the position was formed she did not need urgent intervention and a more extensive eye examination could be done later.
His parents gave evidence yesterday that he barely spoke to them and did not make eye contact.
Dr Teo said this was likely due to the pressure he was under to return with other patients and the need to move quickly due to staffing constraints after at least two doctors fell ill that night.
The symptoms together could indicate sepsis, says the doctor
Mr Hammond told Dr Teo that at the time he examined Aishwarya she had a high temperature, cool peripheries, signs of tachycardia, headache, lethargy or “floppiness”, which Dr Teo accepted when taken together they could indicate the onset of sepsis. .
However, when questioned by his own lawyer, Dr. Teo also acknowledged that these symptoms could also indicate a more common gastrointestinal problem, and that taken alone they were common in children presenting to the ED.
But Dr Teo said if he had been aware of these symptoms and suspected sepsis in Aishwarya, he would have taken her to a higher priority area and started more thorough investigations, which could have included treatment with antibiotics and fluids.
The inquest heard two doctors at PCH had called in sick on the evening Aishwarya Aswath was taken to the emergency department. (ABC News: Keane Bourke)
Coroner Sarah Linton asked Dr Teo if he had “slowed down a bit, talked to the parents a bit, would it have become apparent that his concern was not just about his eyes?”
“Yes, with the benefit of hindsight,” said Dr Teo, who also admitted he regretted not spending more time that day.
Missed opportunity to recognize “something more”
He agreed with the coroner’s suggestion that it was a “missed opportunity to recognize that maybe there was something more to Aishwarya”.
The coroner acknowledged that Dr Teo had thought deeply about the events of that night.
In his evidence, Dr Teo suggested there could be advantages in establishing a rapid assessment team in triage consisting of a doctor and a nurse, which he observed operating during a placement at Sir Charles Gairdner Hospital .
The inquest also heard from an administrative staff member who was working in the ED waiting area when the family arrived.
Aishwarya’s mother approached the employees several times to raise her concerns about Aishwarya’s deterioration in the waiting room.
He gave evidence that employees did not receive specific training on how to refer patients if they raised concerns, but said he relied on common sense.