WA Child and Adolescent Health Department reports five deaths from clinical incidents


The Western Australia Child and Adolescent Health Service (CAHS) has revealed that five children and adolescents have died in their care due to clinical incidents in the last fiscal year.

Each death has been assigned to a “SAC 1 incident,” which includes events where serious harm or death can be at least in part attributed to the provision of health care, or the lack thereof, rather. than the underlying condition or disease of the patient.

Of the 26 SAC 1 incidents confirmed in 2020/21, nine caused serious damage.

In 2019/20, 25 SAC 1 events were reported, four of which resulted in death.

This represents an increase from the 16 confirmed events and three deaths in 2018/19.

A report on Aishwarya Aswath’s death has revealed a “cascade of missed opportunities” at Perth Children’s Hospital.(ABC photo)

“Every clinical incident reflects a time when we could and should have done better for the babies, children and youth we care for,” wrote Aresh Anwar, CAHS Executive Director, in the department’s annual report.

Dr Anwar attributed the increase in deaths to several factors.

“The Child and Adolescent Health Service has a culture of reporting that encourages the reporting of clinical incidents as an opportunity to learn and continue to improve the quality of care and the patient experience,” said he said in a press release.

“We believe the data reflects the reporting culture as well as an increase in bed count and activity from January 1, 2021, with the addition of neonatal services at Perth Children’s Hospital and King Edward Memorial Hospital at CAHS on January 1, 2020. ”

A recognized “devastating” impact

In the report, tabled in Parliament this week, Dr Anwar also paid tribute to Aishwarya Aswath, 7, and Kate Savage, 13, who both died in the care of the service in the past fiscal year.

A photo of a man and a woman holding signs saying
Aswath Chavittupara and Prasitha Sasidharan, parents of Aishwarya Aswath, have asked for changes at the hospital after their daughter’s death.(ABC News: West Matteeussen)

A report on Aishwarya’s death revealed there was “a cascade of missed opportunities” when she presented to Perth Children’s Hospital with a temperature of 38.8 degrees on April 3, 2021 .

Kate died of serious injuries she inflicted moments after leaving an appointment with the Child and Youth Mental Health Department in July of last year.

“Both incidents triggered decisive and immediate action and launched longer-term programs of work focused on improving the delivery of safer and better quality care,” he said.

“We must recognize that the impact of these cases can be devastating.”

Kate smiles for the camera.  She is on a boat, in front of what appears to be a castle or a fort.
The Office of the Chief Psychiatrist has recommended a review of Kate Savage’s death.(Provided: Meron Savage)

The service’s board chair, Rosanna Capolingua, said the two deaths were “a stark reminder of what is at stake.”

“Our hearts go out to their families and we recognize the ongoing pain and emptiness that is part of a family when losing a child,” she said.

“These tragedies bring personal devastation to family and friends.

“I also know the significant impact they have had on the staff of ACSS and on the community at large.”

“It sounds the alarm”: the opposition

Following Aishwarya’s death, the Premier of Washington State said the hospital staff were “beyond their size”.

“[The report] stated that activity levels within the [emergency department] were not a contributing factor, and it also indicated that given the family’s interactions with staff and the emergency department, there were enough staff, ”he said at the time.

But opposition health spokeswoman Libby Mettam said the increase in the number of deaths attributed to SAC 1 events was evidence of a system under strain.

“This sounds the alarm bells and signals a system under extraordinary pressure,” she said.

“More than ever, our health workers are being asked to do more with less, and we have a system that is on its knees.

“We know that there are significant understaffing issues, and I hope that further steps will be taken to address the resource constraints in our health system.”

A spokesperson for Health Minister Roger Cook said the number of SAC 1 incidents and deaths has declined across WA hospitals over the past three years.

He said the Child and Adolescent Health Service had increased its capacity by assuming governance of neonatal services during the same period.


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