Staff at Perth Children's Hospital missed a "cascade" of opportunities to escalate the care of seven-year-old Aishwarya Aswath as she succumbed to a fatal infection.
The confronting finding is contained in a report by WA's Child and Adolescent Health Service, released in full on Monday.
The report finds that Aishwarya's parents, who have accused staff of lacking compassion, raised concerns about her deteriorating condition on five separate occasions after taking her to the emergency department on Easter Saturday.
Within 20 minutes of arriving, Aishwarya's hands were cold, her eyes were discoloured and her respiratory rate and heart rate were significantly elevated.
But the severity of her condition wasn't recognised until an hour and 17 minutes later, when a doctor noticed she had cold peripheries and slurred speech.
She was pronounced dead within two hours of entering a resuscitation bay, having succumbed to an infection related to group A streptococcus.
Members of the CAHS panel reviewed CCTV footage, interviewed staff involved in Aishwarya's care and reviewed her health record.
"The panel found there were a cascade of missed opportunities to address parental concerns and incomplete assessments, with a delay in escalation which may have contributed to the patient's outcome," the report said.
Aishwarya was taken to the $1.2 billion hospital with a fever and triaged by a nurse - who did not check her vital signs - in the second-least urgent category.
"The lack of a comprehensive triage, including a limited primary assessment of the patient ... contributed in a delay in medical intervention," the report found.
When assessed soon afterwards by another nurse - referred to as RN1 - her temperature of 38.8C did not prompt a sepsis investigation.
RN1 was then called to help with resuscitation of another patient, leaving one nurse - already covering for a colleague who had gone home sick - to watch over eight waiting room cubicles for half an hour as Aishwarya continued to deteriorate.
The report highlights meetings dating back to October last year between emergency department staff and members of the executive team which specifically raised "concerns around the safety of children in the waiting room".
Plans for the new hospital to have a triage support nurse who would check patients' vital signs did not progress after it opened in 2018.
Aswath Chavittupara last week said the staff who had treated his daughter had shown the family a lack of compassion.
"We found the staff were a bit rude and we found that the level of humanity that they had was very low," he said.
Parental concern was ticked as "absent" on a patient chart by RN1 despite the couple's increasingly desperate efforts to seek help.
"RN1 stated this is due to the perception that the parental escalation is for inpatient use only," the report said.
Health Minister Roger Cook, who has fended off calls for his resignation, urged the public not to rush to judgment.
"It is not our role to be judge and jury," he told reporters.
"Let the experts do that."
PCH chief executive Aresh Anwar said none of the staff identified in the report were currently working in the emergency department.
Aishwarya's death will be the subject of a coronial inquest.
Mr Cook is yet to reveal details of a planned independent inquiry into the PCH emergency department.
Aishwarya's parents, who are dissatisfied with the CAHS report, say it should also examine other "near-miss" critical incidents at the hospital.
Australian Associated Press