Following triage, Aishwarya was not seen for two hours, despite the fact her parents begged for help five times.
An investigation by the hospital found staff at the emergency department failed to make eye contact with waiting families.
By the time doctors saw Aishwarya, it was too late. She was rushed into resuscitation in a hypertonic condition, and died soon afterwards.
The coroner found she died of multi-organ failure due to sepsis.
PCH’s analysis of the causes of Aishwarya’s death was troubled from the outset.
The young girl’s family found it difficult to communicate with the hospital team, and later, they found discrepancies in the final report.
These issues exacerbated the family’s distrust of the hospital.
An independent inquiry, commissioned by the Western Australian government in the wake of the hospital’s report, met with the family six times, although meetings had to be conducted virtually due to the pandemic. Their report was handed down this week.
The pandemic had led to difficulties finding staff to work at that time, the report states.
The layout of the new hospital also caused difficulties, with the configuration of the emergency department waiting room already flagged as a major concern.
Aishwarya’s family told the inquiry they have suffered “immense loss, anguish and pain” following the death of their daughter.
They expressed “anguish, anger and disbelief,” over the death and the aftermath, and said “urgency, communication and compassion” were inadequate.
The hospital is in the process of implementing the changes it recommended in its 10-point plan, including increasing the number of nurses on staff.
The more recent inquiry has made an additional 30 recommendations, which the Western Australian government has committed to implementing.
Health Minister Roger Cook said all 30 recommendations will be accepted and acted upon immediately.
Earlier this week Aishwarya’s father, Aswath Chavittupara, told 7NEWS he believed PCH is still trying to “defend” itself against accusations of understaffing and inadequate care.
“I’m still surprised they’re still trying to defend their actions,” he said.
“If they came out with the truth and admit their mistakes, then we can start a new chapter.”
Cook said it is important that parents have the confidence to take their children to PCH.
The new report makes “a range of observations about the exemplary level of care at PCH,” he said.
“It performs extremely well and people can be very confident of it.”
However, Chavittupara said his family would not take their children to the hospital if they were sick.
“We wouldn’t feel safe taking our other children there, not at the moment,” he told 7NEWS.
“We are emotionally not in the state to visit PCH.
“We need to build a bit more trust before we can get to that stage,” he said.
Meanwhile, the family continues to suffer heartbreak.
“We will love and miss Aishwarya for the rest of our lives,” Chavittupara said.