Coroner rules eight-year-old’s hospital death could have been avoided

In a Wednesday inquest, Deputy State Coroner Paresa Spanos determined that the death of eight-year-old Amrita Varshini Lanka at Monash Children’s Hospital was preventable. Amrita arrived at the emergency department on April 29 with two days of gastrointestinal symptoms; after appendicitis was ruled out, staff treated her for gastroenteritis. Early on April 30 her mother reported chest pain, prompting an ECG at 3.30 am that showed abnormalities and a blood test revealing elevated lactate, indicating deterioration.

Registrar Patrick Tan suspected myocarditis but did not recognize the seriousness, failing to re-examine her until 5.30 am, by which time she suffered a brief cardiac arrest. She was escalated to senior clinicians and transferred to Royal Children’s Hospital at 8.51 am, but remained in prolonged cardiac arrest and could not be saved. Monash Health admitted the staff missed the severity, implemented internal reviews and new notification rules, and the coroner praised these changes while offering condolences to the grieving parents.