Western Australia's premier insists his health minister won't be sacked over the failure at a Perth hospital which left a young girl dead.
Seven-year-old Aishwarya Aswath spent two hours waiting in the emergency department at Perth Children's Hospital (PCH) after presenting with a fever during the Easter weekend.
Her parents had pleaded 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.
Aishwarya's parents are understood to be unsatisfied with the findings and plan to make a public address on Thursday.
The Australian Medical Association and state opposition are calling for Health Minister Roger Cook to resign following months of concerns about understaffing, treatment delays and record ambulance ramping at Perth's hospitals.
But Premier Mark McGowan on Thursday said Mr Cook had "done a very good job for over four years".
"It is a big job, a big workload, a big system and to manage that entire workload is very difficult," he told reporters.
"We do have issues occur and this is clearly a big issue."
Mr Cook has claimed that staff shortages did not contribute to the incident.
But a summary of recommendations from the confidential CAHS report, tabled in state parliament, highlighted a reduction in available medical staff.
"These factors may have contributed to a delay in recognition of the severity of illness and initiation of treatment," it said.
The premier said he had been advised there was a "very high" staff to patient ratio that night, including an additional doctor on duty.
"I'm not going to point any fingers at anyone," he added.
"Clearly, I think what we need is further analysis of what went on, which is why I'd like to see a coronial inquest."
Mr Cook has ordered an independent inquiry into the PCH emergency department and "any matters of specific concern" identified by Aishwarya's family.
Opposition health spokeswoman Libby Mettam said the minister had his head in the sand about the state of the health system.
"I'm not sure what report (he) was reading but the buck stops with him," she said.
AMA WA president Andrew Miller said doctors had been warning for more than a year of emergency department overcrowding which could lead to a tragedy.
"I really think that it's time for a new health minister," he told Perth radio 6PR.
The government has accepted the resignation of CAHS chair Debbie Karasinski, who Dr Miller described as a "sacrificial lamb".
The report included 11 recommendations 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.
A review of staff awareness of culturally and linguistically diverse communities is also recommended.
"The perceived lack of cultural awareness by staff for CALD families and patients may have resulted in non recognition of the family's significant concerns whilst attempting to escalate care," the summary said.
Aishwarya's grieving parents went on a hunger strike outside PCH this month after calling for an independent inquiry into their daughter's death.
Mr Cook has apologised, saying it was clear Aishwarya and her parents should have received better care.
