There was a "small possibility" a seven-year-old girl who died of sepsis after waiting almost two hours to be admitted to Perth Children's Hospital (PCH) might have lived if she had received care sooner, a coronial inquest has found.

The state's deputy coroner has handed down her long-awaited findings into the death of Aishwarya Aswath after her parents brought her into the hospital's emergency department (ED) one afternoon in April 2021.

Aishwarya's parents Aswath Chavittupara and Prasitha Sasidharan, through their lawyers, said the findings had produced "mixed emotions".

"It has been incredibly upsetting for them to read what they have always known, that Aishwarya was deprived of the chance of survival by a series of missed opportunities as a result of systemic problems at Perth Children’s Hospital," the statement said.

"However, Aswath and Prasitha are also grateful that the Deputy State Coroner has taken the time to consider all of the evidence presented to the court, and arrive at the conclusion that the health system tragically failed Aishwarya and her family on that fateful day.

"Their mission has always been to ensure that Aishwarya’s death was not in vain and that improvements are made so that no other family has to endure what they have.

"We would urge the government to make sure that the Deputy State Coroner’s five recommendations are implemented as soon as possible."

Coroner Sarah Linton's recommendations included mandated patient-to-staff ratios in all public hospitals and a dedicated resuscitation team to be stationed at PCH emergency.

Other measures included protections for nursing staff from regulatory investigation and prosecution when workplace risks are involved in an adverse outcome, changes to the records keeping system in state hospitals and new triage policies.

Aishwarya's parents have previously said they would "never forgive" the WA Health system but stressed they wanted the focus put on that system rather than individuals working within it.

Ms Linton commended their bravery and unwavering commitment in seeing the process through.

She also recognised many of the staff who gave evidence at the inquest were "deeply affected" by Aishwarya's death.

And while she noted many changes had been implemented in the wake of Aishwarya's death, she said it should not have come at such a cost.

Health Minister Amber-Jade Sanderson said the government had already started implementing most of the coroner's recommendations after Aishwarya's death.

The coroner found there was a "small possibility" Aishwarya might have lived if she had received care sooner.

Ms Sanderson says four out of five of the recommendations are already being acted on, including boosting nurse-to-patient ratios before pay negotiations with nurses are concluded.

Tragic missed opportunities in lead up to little girl's death

On 3 April 2021, the family had become worried by Aishwarya's listlessness, fever and very cold hands.

Nonetheless she was triaged at a relatively low priority and asked to go to the ED waiting room before she could be seen by a doctor.

What happened next has been described as a "cascade of missed opportunities" as staff failed to notice her quietly deteriorating despite her parents' best efforts to raise the alarm.

Today Ms Linton said the tragedy could have been prevented "if she had been given urgent medical treatment shortly after she first arrived at PCH".

Urgent healthcare reform recommended

Ms Linton recommended all public hospitals implement a 1 to 4 nursing staff-to-patient ratio advocated by Australian Nursing Federation (ANF), with particular priority given to EDs.

The coronial inquest last year heard from frontline staff, including the nursing shift coordinator, that the nurse to patient ratio in the ED was "insane".

Since Aishwarya's death the WA government has spent $20.5 million on the ED to hire another 46 nurses, doubling the existing team.

The nurses union made patient-to-staffing ratios part of their recent contract negotiations.

The WA Government last year committed to phasing in the ratios over two years, down from the three years initially put on the table.

Ms Linton said there was no reason the ratios could not be actioned earlier as "a matter of priority".

"Patient safety should not wait for the outcome of such [union and government] negotiations when the department of health's own independent inquiry supports such a change," the coroner said.

Dedicated resuscitation team needed

Ms Linton recommended the Child and Adolescent Health Service (CAHS), which is responsible for PCH, implement a dedicated resuscitation team.

The inquest last year heard from the nurse who assessed Aishwarya while she was in the waiting room was also filling an informal role as a "floater nurse" and her assessment was interrupted by other tasks.

She was required to attend an emergency resuscitation incident before completing her assessment which left Aishwarya unattended in the waiting room.

An independent review recommended a dedicated resuscitation team be put in place but the inquiry a hospital executive gave evidence that the positions are funded but it had yet to fill them amid a difficult recruiting environment.

The health minister said a team was now in place and fully staffed.

'Safe harbour' for nurses who blow whistle on employers

In the wake of Aishwarya's death, hospital management reported three nurses and a doctor to the national medical worker watchdog, the Australian Health Practitioner Regulation Agency (APHRA).

The agency investigated but did not make adverse findings.

The Australian Nurses Union retaliated by referring hospital executive members to the agency for investigation, for failing to heed staff warnings that dangerous levels of understaffing were impacting patient safety.

The ANF said they met with the hospital's executive team in December, three months prior to Aishwarya's death, to raise concerns.

The coroner recommended the WA Government introduce "safe harbour" provisions to protect nurses from APHRA investigation and prosecution when an adverse event occurs where "known risks in the workplace have been identified and not rectified by the employer".

The inquest heard notes taken by nurses were in some cases not immediately transferred to digital systems, and there were multiple forms that needed to be filled out was said to add to the time, frustration and stress for nurses.

The health department said it was transitioning from paper to a state-wide electronic medical records system but coroner Sarah Linton said the government must prioritise funding these changes.

Changes to triage procedure

The triage nurse on duty the night Aishwarya arrived gave evidence she did not take observations such as heart rate or temperature.

At the time a large screen had been installed to reduce COVID transmission risk, and the intake desk put a distance between patients and the triage nurse.

Australasian College for Emergency Medicine guidelines do not require observations to be taken at triage, but the nurse said she had previously done so in other regional hospitals including Broome.

The hospital undertook a literature review following Aishwarya's death and determined there was no strong evidence that taking one or more vital signs at triage improved clinical outcomes.

However Ms Linton said it was her view that to prevent sepsis from being missed it was important to give priority to the first set of observations taken in children.

She recommended CAHS give consideration to implementing a new procedure for observations to be taken at triage or alternatively, within half an hour by the waiting room nurse, at PCH, when children present with gastrointestinal symptoms. 

"This will ensure there is an early benchmark to measure the child’s progress and monitor for signs of sepsis," she wrote.

'Nurses and midwives are over-stretched'

The Australian Nurses Federation (WA) state secretary Janet Reah said in a statement she was pleased the coroner had adopted three recommendations from the ANF.

"It couldn't be clearer. Nurses and midwives are over-stretched and hospitals are drastically understaffed in both the public and private sectors," Ms Reah said.

"There is no point in having a state-of the-art facility, if the staff working within it are stretched beyond capacity and parents lose their trust and faith in them."

Curtin University nursing professor Phillip Della said the recommendations were "solid and robust" and needed to improve improve the working lives of nurses and other health professionals.

"The recommendations are based on years of evidence that show that where we have safe staffing levels, patient care improves and the retention of our staff improves.," Professor Della said.

Australian Medical Association WA president Mark Duncan-Smith says the WA government should extend the "safe harbour" provisions to doctors as well as increasing the operational budget of WA Health.