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Letter from Australia

MMF’s Australia Associate Sue Mcnaughton, reports on a recent case which highlights how communication breakdown contributed to the tragic death of a child

On April 3^rd 2021, a seven year old girl called Aishwarya Aswath died from sepsis after a two hour wait in the emergency department of Perth Children’s Hospital, one of Australia’s leading children’s hospitals. Her parents repeatedly but unsuccessfully, tried to engage with the medical staff on duty as they observed the rapid deterioration in their daughter’s condition.

This tragic case highlights the potential risks of failing to provide caring health professionals with specific training in listening and responding to, the concerns of parents, particularly in situations of acute anxiety and distress.

The hospital-led Inquiry into Aishwarya’s death identified a “lack of recognition of persistent and significant parental concerns as a significant clinical concern to be escalated” which “resulted in a delay in treatment which may have contributed to the patient’s outcome”.

When Aishwarya’s family were asked to share their concerns and perceptions with the Independent Inquiry into her death which followed, “they expressed anguish, anger and disbelief. Urgency, communication and compassion were felt to have been inadequate.” The Independent inquiry also described “gaps in communications, perceived attitudes, engagement, compassion and empathy”

One of the most striking aspects of the independent inquiry’s report is its focus on the connection between failures in communication and increased clinical risk.

The report highlights, “challenges in acknowledging and adequately responding to parental concerns regarding severity and deterioration” and concludes that: “It is an essential component of paediatric clinical care to “listen to the parent” and to appreciate the “unique role of the parent in recognising early signs of illness or deterioration.”

Of even greater concern perhaps was the finding that the parents also “shared concerns regarding their culturally determined propensity not to be assertive and apply pressure to staff, despite their fears and sense of abandonment”. Aishwarya’s family were from a culturally and linguistically diverse (“CALD”) background and it was accepted that this was a factor in the response from the staff on duty. One key recommendation was that “measures be designed and implemented to identify and monitor health care utilization by CALD patients and families”.

This case was a tragedy for Aishwarya’s family (family photo, right) but it was also devastating for the hospital staff who were working under extraordinary pressure

trying to manage large numbers of sick children while battling staff shortages and a recent move to a new hospital building. As Western Australia’s Health Minister said, “this tragic event has been deeply felt by staff” across the children’s hospital.

To what extent did a breakdown in communication between staff and Aishwarya’s family contribute to her death? The report concludes that it was a significant factor and recommends that: “the importance of the parent’s extraordinary role in the recognition of deterioration, or indeed any change in the behaviour or health status of their child, be reinforced and embedded throughout all clinical and administrative protocols and training curricula.”

However, as with other cases where “failures” in communication have been identified as significant contributory factors, there is a more complex story to tell. The underlying theme of a failure to listen, of parents saying “we told them there was something wrong but they just weren’t listening” is one we hear with frightening regularity but it is multi-layered.

Listening skills can be just as important as clinical skills and like clinical skills, they need to be taught.

As the report into Aishwarya’s death illustrates, a failure to provide caring health professionals working under pressure with the tools to support them in having difficult and compassionate conversations, can lead to consequences as severe as, for example, a failure to adhere to rigorous clinical hygiene procedures on a hospital ward.

The report into Aishwarya’s death highlights this, citing specifically a lack of training “on communication … [in] challenging scenarios and difficult conversations, as well as structured communication across all aspects of care”

In conjunction with recommendations regarding staffing levels, system policies and practices, key recommendations were that the hospital “expand [its] capacity to train and support staff in communication, partnering with consumers and customer relations” as well as the expansion of measures to enable staff to access leave and continuing education.

So what are the lessons that can be learnt from Aishwarya’s death?

Often, relational challenges that treating teams can face with families appear to be inherited from a family’s interactions with a previous team or a previous hospital. Their trust in health professionals may have been eroded for many different reasons but the common underlying themes are often “poor communication”, “unrealistic expectations” and “avoidance of difficult conversations”. In mediation work across many fields, whether medical, commercial, or family, most disagreements arise from these factors. Fundamentally, people have a very real and very understandable reluctance to engage in conflict, fearing confronting and emotional conversations. The trouble is, of course, that a problem ignored does not become a problem resolved; the reverse usually occurs and conflicts tend to escalate if they aren’t addressed quickly, sensitively and skillfully.

In 2020, just three weeks before the start of the pandemic, I flew to Auckland, New Zealand, to join my MMF colleagues in delivering an intensive fortnight of training in recognizing and managing conflict to senior staff at Starship Children’s Hospital. Following some challenging cases of their own, they wanted to provide their staff with the skills and confidence to manage conflicts with families. This work has continued virtually throughout the pandemic and staff have reported that their approach to communicating with families and recognizing potential conflicts early, has improved significantly.

Training staff to feel confident and supported in managing challenging conversations with families is only one part of the equation.

There are issues which it is not reasonable to expect staff to resolve and that is where specialist mediation services come in. Many health care professionals have described to me how they have found themselves ensnared in disputes/complaints which have become legalized far too quickly and caused enormous damage to themselves and to the families involved.

As a former litigation lawyer I understand all too well how this happens, but as a mediator I am frustrated that mediation is not routinely offered as a first step in Australia, if at all, as a potential avenue for resolving disputes over medical care and treatment. Too often a family that is “difficult” is a family that is under extreme pressure and suffering enormous pain. They may have valid cause for complaint. They may not. Either way, a court environment is not usually going to help them, or their child, or the professionals caring for their child. But a mediation room might do. My recent experience of working in this field suggests that mediation and training in recognizing and managing conflict between families and health professionals are at least worth considering.