The parents of Aishwarya Aswath, the seven-year-old who died of sepsis within hours of presenting to an under-pressure ED, have called for improvements in hospital staffing to prevent a repeat tragedy.

Aishwarya waited more than 90 minutes before being formally assessed by a doctor, in a case that triggered a political firestorm with nursing staff subsequently referred to AHPRA for alleged failures in care.

In findings delivered on Friday, Deputy State Coroner Sarah Linton found there was a “small possibility” that she may have been saved if proper treatment had been initiated when she arrived at the hospital. 

But she made five key recommendations, including the implementation of nurse-to-patient ratios and a standalone resuscitation team at Perth Children’s Hospital where Aishwarya was treated.