Last month a confidential government investigation into the tragic death of Aishwarya Aswath at a WA hospital was made public by her heartbroken parents.

It found staff in at Perth Children’s Hospital had missed a “cascade” of opportunities to escalate care for the seven-year-old as she succumbed to a fatal infection on Easter Saturday.

Within 20 minutes of arriving at the empty ED triage, Aishwarya’s hands were cold, her eyes were discoloured and her respiratory and heart rates were significantly elevated, found the report based on CCTV footage, medical records and statements from 25 hospital staff.

But the severity of her condition wasn’t recognised until one hour and 17 minutes later, when a doctor noticed she had cold peripheries and slurred speech.