The Western Australian government has apologised for the "failure" at a Perth hospital which left a young girl dead after her parents' desperate pleas for help were ignored.
Seven-year-old Aishwarya Aswath spent two hours waiting in the emergency department at Perth Children's Hospital (PCH) after presenting with a fever and being triaged in the second-least urgent category during the Easter weekend.
Aishwarya's parents had begged for her to be assessed by doctors after her eyes became cloudy and her hands turned cold.
She died soon after she was finally seen.
A report by WA's Child and Adolescent Health Services (CAHS) has found Aishwarya died of sepsis after contracting an infection related to group A streptococcus.
Health Minister Roger Cook summarised the confidential report in parliament on Wednesday, saying it was clear Aishwarya and her parents should have received better care.
"They did not get the help they asked for," he said.
"I wish to apologise unreservedly for this failure and for the heartbreak and devastation Aishwarya's death has caused her family and her community."
Mr Cook later told reporters he had accepted the resignation of CAHS chair Debbie Karasinski.
The organisation's chief executive Aresh Anwar said he had also offered his resignation but had been asked to continue by the director-general of the health department.
Mr Cook, who described the report as "confronting and extremely distressing" would not be drawn on whether Aishwarya's death could have been avoided.
"We don't know. And that's not a conclusion of the report," he said.
"Hospitals are, by their nature, complicated workplaces where decisions often have to be made quickly and in the most difficult of circumstances.
"I have the utmost respect for the doctors and nurses working in our hospital system. They do an amazing job under difficult circumstances."
Mr Cook has ordered an independent inquiry into the PCH emergency department and "any matters of specific concern" identified by Aishwarya's family.
He said the hospital continued to perform well against safety and quality measures.
Aishwarya's death followed months of concerns about understaffing, treatment delays and record ambulance ramping at Perth's hospitals.
Four emergency doctors were off sick on the night in question but the report found staff shortages had not contributed to the incident, Mr Cook said.
The report included 11 recommendations, all of which the government has agreed to implement at PCH within the next six months.
They include improvements to the triage process policy and staff education, improved clinical supervision, and development of a "clear pathway" for parents to escalate their concerns to staff.
The report also recommends developing an established sepsis recognition diagnostic tool, and a review of staff awareness of culturally and linguistically diverse communities.
However, Mr Cook downplayed any potential race-related concerns.
"None that (the panel) spoke to believed that race played an issue in relation to the care of Aishwarya," he said.
It's understood Aishwarya's parents are unsatisfied with the findings and plan to make a public address in coming days.
The grieving couple went on a hunger strike outside PCH earlier this month after calling for an independent inquiry into Aishwarya's death.
Labor last week used its parliamentary majority to block such a probe, saying four of the 10 panellists on the CAHS inquiry were independent.
Opposition health spokeswoman Libby Mettam said it was "abundantly clear that our health system is in crisis".
Australian Associated Press