Seven-year-old Aishwarya Aswath was carried into the emergency department of Perth's state-of-the-art children's hospital a little over a year ago.
She never got to walk back out.
Now her parents — Aswath Chavittupara and Prasitha Sasidharan — will finally hear from the nurses and doctors who oversaw her care as a coroner today begins examining in detail the events that led up to her death.
Family spokesman Suresh Rajan said Aishwarya's parents were hoping to find out exactly what took place at Perth Children's Hospital that night.
"Just so they have some closure as to exactly what happened to their daughter," he said.
"To this day they have a few suppositions but nothing definitive as to what transpired on that night."
The little girl's treatment and her subsequent death sparked two reviews and an overhaul of how hospital emergency rooms across Western Australia operated.
It also led to the departure of the WA Child and Adolescent Health Service (CAHS) board chair Debbie Karasinski AM, who tendered her resignation in May last year after reading the internal review of the incident.
CAHS chief executive Aresh Anwar also offered to resign at the time but it was not accepted.
His resignation was ultimately accepted earlier this month, about two weeks out from the start of the coronial inquest.
Treatment decisions under microscope
Aishwarya waited almost two hours for treatment after being assessed as a low priority for immediate care, despite her mother repeatedly asking the emergency department waiting room nurse for help.
The inquest is expected to hear from three registered nurses — including the one who initially assessed Aishwarya but was then pulled away to another emergency for a patient with spinal trauma.
It is also likely to hear from the registered nurse that ultimately noticed Aishwarya was having difficulty breathing and ordered her taken to the resuscitation area.
She was found to have been suffering from a sepsis infection.
Following Aishwarya's death, CAHS referred two junior nurses and a doctor to the medical regulation watchdog, the Australian Health Practitioner Regulation Agency, over the incident.
The inquest is likely to hear whether that agency took any action against those workers.
The move angered the doctors and nurses unions amid concerns junior medical staff were being made scapegoats.
The unions referred Dr Anwar, WA Health Director-General Dr David Russell-Weisz and three senior nursing executives to AHPRA in response.
Australian Nurses Federation secretary Janet Reah said she hoped the inquest would help establish what safe staffing levels in WA hospitals looked like.
"Not minimal staffing, safe staffing," she said.
Staffing levels a worry in lead-up to tragedy
Ms Reah said staff had repeatedly raised concerns about staffing levels in the lead-up to Aishwarya's death.
"The government's shown that they're very slow to listen to our concerns, but they're very quick to throw nurses under the bus when something goes wrong," she said.
She said staff were frightened to go to work believing they would not be supported if the system broke down.
"Not only have you got the fear of 'will I do well enough today', you've got the fear that something you can't control because the system is broken, that you're working in, and it comes back on you," she said.
The confidential "root cause" internal review completed by the hospital, seen by the ABC, found a "cascade of missed opportunities to address parental concerns and incomplete assessments, with a delay in escalation" may have contributed to Aishwarya's death.
It made 11 recommendations including the establishment of a triage support nurse, a better process for parents to escalate their concerns, redesign of the PCH emergency department and more training for junior staff.
Staff described as 'exhausted, demoralised'
An independent, external investigation was then ordered after Aishwarya's parents began a hunger strike outside the hospital.
That report said ED staff were "described as exhausted, demoralised and relatively isolated".
"Staffing and rostering challenges, along with the inability to backfill higher than usual sick leave, may have further contributed to workload pressures in the ED," the report said.
That report made 30 recommendations, of which the government says six have been implemented.
WA Health Minister Amber-Jade Sanderson pledged all 30 would be implemented over the next 12 months.
Ms Sanderson said she didn't want to pre-empt the results of the coronial inquest, but that the government would consider all the recommendations that came from the coroner.