Coroner finds Amrita Lanka's 2022 death in Monash ED was preventable

Mixed · 2Victorian Deputy State Coroner Paresa Spanos found on Wednesday 14 October 2026 that the death of eight-year-old Amrita Lanka from myocarditis in 2022 was preventable. 1 2 Mixed · 2Amrita was referred to the paediatric emergency department at Monash Medical Centre in Melbourne by her family doctor on 29 April 2022 after two days of nausea, vomiting, diarrhoea and abdominal pain. She was alert and her vital signs were normal when triaged shortly before 1pm. 1 2 Mixed · 2Doctors made a working diagnosis of gastroenteritis, and she was placed in a cubicle with no allocated nurse. Her mother, Satya Tarapureddi, told the ABC in 2022 that Amrita later said she had "hard breathing" and that nobody came when she pressed the staff assistance button. 1 2

Mixed · 2The overnight registrar, Dr Patrick Tan, reviewed her at about 3:20am on 30 April. An electrocardiogram was abnormal and he suspected myocarditis, but he told the inquest he did not appreciate how severe her condition was. He said he was 12 weeks into his first paediatric rotation and in charge of about 18 patients. 1 2 Mixed · 2Further blood tests were ordered, but no one properly attended to Amrita until about 5:30am. A troponin test, which measures heart muscle damage, came back above 27,000 nanograms per litre; the normal level is below 10. 1 2 Mixed · 2Amrita was moved to the acute section of the emergency department and suffered three cardiac arrests, the last shortly after a retrieval team from the Royal Children's Hospital (RCH) arrived. She died less than 24 hours after triage. 1 2

Mixed · 2Spanos said Tan's clinical management and care was "wanting" and caused or contributed to the death, while accepting that emergency departments are busy and Tan was relatively junior. She said timely escalation and an earlier transfer to the RCH, which has specialised life support for children with critical heart and lung conditions, could have saved Amrita. 1 2 Mixed · 2Other missed opportunities included high lactate levels and a low blood-pressure reading that should have triggered a medical emergency call. By 8am Amrita was getting a high level of care from Monash doctors, but Spanos said "the die was already cast". Two other doctors involved in her care were cleared. 1 2 Mixed · 2Monash Health conducted its own review in 2022 and admitted failings. The coroner said it has since changed practices and policies and improved staff education. In a statement, it said it would carefully consider the findings and had made changes to strengthen patient monitoring, escalation of care and communication. 1 2

Mixed · 2Spanos paid tribute to Amrita as a talented child who loved art and animals, especially birds, and played the piano. Her mother had earlier called the thought that better care might have saved her daughter "torture". The ABC adds that Victoria trialled a hotline for parents worried about their children's hospital care in 2024, the Kids Urgent Concern Helpline, which was expanded state-wide in July 2026. 1 2