A year ago on Sunday Aishwarya Aswath died at Perth Children's Hospital, just three hours after her father, Aswath Chavittupara, had carried her into the emergency department.
Aishwarya died despite her mother Prasitha, Sasidharan, making five visits to the waiting room desk, concerned about her daugher's condition in the 94 minutes she waited to be seen.
An independent report found the fact the waiting room nurse was called away on that day to resuscitate another patient "may have contributed" to her death.
In response to that report, a waiting room nurse role was introduced at Royal Perth Hospital (RPH).
But two nurses the ABC has spoken to on the condition of anonymity are claiming that in recent months, the role was often unstaffed, and since the West Australian border opened on March 3, it had been abandoned altogether.
One of the women, who the ABC is calling Jessica, is a clinical nurse currently working in RPH's ED who blames staff shortages for the move.
"Our triage is split in between a [COVID] tent that's outside and then the main ED waiting room and there's no one who's overlooking those patients who are waiting at all, except for your triage nurses, if they have capacity," Jessica said.
Jessica said the waiting room nurse role had been effective.
"We did pick up patients who had deteriorated in the waiting room but didn't have anyone who could flag that with us," she said.
An RPH spokeswoman said the waiting room nurse role was "briefly" moved to the "COVID waiting room" when case numbers increased markedly.
"Subsequently, the role was expanded to both the main waiting room in the hospital and the assessment ED marquee," she said.
Patients who should be seen within 10 minutes are waiting for 30 minutes in tent
Like many hospitals, RPH has set up a COVID-19-screening tent outside, in a bid to prevent the virus from spreading throughout the hospital.
After being screened, suspected COVID-19 patients are then supposed to be seen in a negative-pressure room inside.
RPH has 11 negative-pressure rooms, but Jessica said that, even when they were not full, they sometimes could not be used because of a lack of trained staff.
She said that meant patients triaged as category 2 — the second-most serious, classified as "emergency" and needing to be seen within 10 minutes — were often waiting much longer.
"We've had patients who have presented to RPH ED with chest pain … (waiting) 20 to 30 minutes out the front of the ED, to actually even be able to be wheeled inside, because we've got no bed space," Jessica said.
Responding to the claim, the RPH spokeswoman said that "a range of provisions" were in place, "should all 11 [negative-pressure] rooms be in use."
However, Jessica said, she was genuinely worried that bed and staff shortages would see another patient die in similar circumstances to Aishwarya.
Jessica said that she supported staff being held accountable when patients died in preventable circumstances but also said she felt the culture at RPH had shifted in recent months to one focused on ensuring there would be someone to blame if something went wrong, rather than helping staff prevent mistakes with adequate resourcing.
"Even those patients who wait 20 minutes for a bed inside, [senior management] will be like, 'If you recognised that they were deteriorating, why didn't you get them through quicker' [and I think], 'How? How do I escalate that any further than I have already?'" she said.
"I feel like I'm going to lose my registration … There's been, at least, 10 senior staff members who have left the department over the last few months and what goes through their head is, 'Why should I put my registration on the line when I'm working my ass off trying to do the right thing by these patients?'"
The RPH spokeswoman said the hospital "strongly" disputed Jessica's claim regarding a culture of blame.
"RPH prides itself on patient-centered care and continuously strives to find solutions and improve care," the spokeswoman said.
"The ED has doubled the number of senior nursing positions during the past six months, to help ensure that all staff receive adequate support and optimal levels of staffing are maintained."
One staff member who quit three weeks ago, an ED nurse who the ABC is calling Michelle, said that, when she became a nurse nine years ago, she loved it and felt it was "a calling".
However, Michelle said, increasingly aggressive patients, a lack of support from RPH, and an "unsafe" workload, became too much.
"So, I think that people are very disheartened and a lot of people don't want to go to work and there's lots of sick calls," she said.
No recognition of unsafe work reports or 'appreciation' for nurses
Jessica said RPH staff were supposed to submit what was called a Combined Hazard or Incident Reporting (CHoIR ) form if they had witnessed or experienced a dangerous situation.
However, for the past two years, she said, the reports had been met with silence.
"I'm sure that [management] are reading those CHoIR forms and I'm sure that they are aware of them, but there's no feedback … or recognition," she said.
Jessica said she didn't want to come across as a "whingeing nurse" and acknowledged that West Australian nurses had not had to deal with hundreds of dying COVID-19 patients, like their counterparts interstate and overseas.
She also knew the hospital was trying to recruit more staff.
However, she said, there were things WA Health could have done in the past two years, while the state was relatively COVID-free, to prepare and show they valued nurses.
These included increasing the number of toilets in RPH's ED from just two male and two female and ensuring nurses had somewhere to sit during their tea breaks.
"WorkSafe has come in recently and said that there's only meant to be six people inside that area [the staff tearoom] because of COVID … which is understandable," she said.
"[But] that includes people who are waiting for the toilet, who are waiting for their meal to heat up," she said.
"[RPH] have taken away the desks and they've only left that number of chairs, just to enforce that, rather than looking at a solution," she said.
Michelle described the tearoom situation as a "little bit of a slap in the face when you're just trying to work really hard".
"I don't mind working hard," Jessica added.
Through its spokeswoman, RPH said it had implemented a "Stop the Violence" campaign and increased the number of security staff in the ED over the past year.
She also said RPH disputed Jessica's claim about CHoIR forms.
"RPH ED has worked with health and safety representatives who investigate every CHoIR and report and escalate issues raised," she said.
The spokeswoman said there were four additional toilets that ED staff could use on the floor below, "within the unit's staff designated locker rooms".
She added that, regarding the tearoom, staff were encouraged to take breaks "in the fresh air" and that there was "a large, staff-only HUB on-site with ample comfortable couches, kitchen tables and chairs, TV and coffee machines."
In its own statement, WA Health said it was "committed to the health and wellbeing of staff".
"The Department of Health and health service providers have been making ongoing, concerted efforts to recruit and retain healthcare staff in what is a challenging labour environment around the world," the statement said.
"This has included the Belong local, national and international recruitment campaign, and relocation incentives [flight and hotel quarantine costs] for international health professionals to move to work in health in Western Australia, and fast-tracking of local nursing and midwifery graduates into jobs."
