HYDERABAD: The coroner of Australia’s Victoria found that the death of eight‑year‑old Amrita Varshini Lanka, a Telugu‑origin girl who died at a Melbourne hospital in 2022, was preventable. She criticised the emergency department doctor for failing to recognise the seriousness of her condition.
Deputy state coroner Paresa Spanos handed down her findings on Wednesday, saying Amrita’s life could have been saved if the doctor had recognised and treated her deteriorating condition in time. Her father, Chandra Sekhar Lanka, and mother, Satya Tarapureddi, who were present in the courtroom, nodded and wiped away tears as the findings were read out.
Amrita died from lymphocytic myocarditis, an inflammation of the heart muscle, at Monash Medical Centre on April 30, 2022. She was brought to the hospital’s emergency department around 1 pm on April 29 after suffering stomach pain, nausea and vomiting for two days.
After tests ruled out appendicitis, doctors suspected gastroenteritis. Early the next morning, her mother raised concerns that Amrita was experiencing chest pain and shortness of breath.
Emergency department registrar Dr Tan consulted another doctor, who agreed with his preliminary diagnosis. However, neither recognised the severity of the girl’s condition, the coroner said.
Although tests showed elevated lactate levels, indicating deterioration, her blood pressure was not measured. Dr Tan believed she did not appear unwell and did not check on her again until 5.30 am, by which time her condition had worsened.
Senior clinicians were subsequently involved, but Amrita suffered a brief cardiac arrest at 7.30 am. An emergency transfer to the Royal Children’s Hospital was arranged. By the time the transfer team arrived at about 8.51 am, she had suffered a prolonged cardiac arrest and died.
“Certainly, when the ECG had been completed and the elevated lactate was available, Amrita’s life could have been saved,” Spanos said.
The coroner said Dr Tan’s clinical management and care were inadequate, contributing to the child’s death. Monash Health admitted during a 2024 inquest that staff failed to appreciate the seriousness of her condition.
While the coroner made no formal recommendations, she said the hospital introduced changes after an internal review, including requirements for clinicians to notify on‑call consultants in specific cases.
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