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A blood test two days before his death would have revealed Sandipan Dhar’s undiagnosed leukemia and likely saved his life, the WA coroner has found.
Sandipan died in the emergency department at Ramsay Health Care’s Joondalup Health Campus on March 24, 2024 due to complications from undiagnosed acute blastoma leukemia, a curable blood cancer identifiable with a blood test.
In her 86-page findings, Acting State Coronor Sarah Linton rejected Ramsay’s submissions to the inquest that she could not determine whether his death was preventable, concluding that a blood test on his first presentation to the hospital on March 22 could have saved the 21-month-old’s life.
“This was more than a missed opportunity,” she said.
“I find on the balance of probabilities that had blood tests been performed on 22 March 2024, Sandipan’s leukaemia would have been identified, and he would likely have survived with definitive treatment; his death was therefore probably preventable.”
However, Linton made no finding whether the Joondalup Health Campus staff provided reasonable care by not performing a blood test.
The coronial inquest was held in May last year and heard evidence from Sandipan’s father Sanjoy, doctors at the GP clinic he was taken to in the weeks prior and staff in the Joondalup Health Campus emergency department.
Its purpose was to determine whether a blood test could have picked up his cancer and triggered treatment.
Sandipan’s death shocked the WA community and once again turned the spotlight on WA’s struggling hospital system, raising questions about the level of care he was provided and whether the cultural background of his parents contributed to crucial communication errors.
Linton said Sandipan was, by all accounts, a remarkable little boy.
“He had always been healthy and well until the last few weeks before his death,” she said.
Sandipan had been suffering a long-running mild fever in the month prior to his death and he had been to GPs several times.
His concerned parents took him to Key Largo Medical Centre in Clarkson on March 20, where a GP noted his mildly elevated temperature, pus on his tonsils, and a mildly inflamed right ear.
He was prescribed paracetamol and antibiotics.
Sandipan’s symptoms persisted, and his family returned to Key Largo two days later with a temperature of 38.3 degrees.
The parents requested a blood test, but were sent to Joondalup Health Campus with a letter from the GP recommending a urine and blood test as part of a sepsis screen.
It was during this visit that Dhar said his family requested a blood test at least three times.
This was disputed by Joondalup Health Campus operator Ramsay Healthcare and supervising ED consultant doctor Dr Yii Siow during the coronial inquest.
It was concluded he had viral tonsillitis, and no blood test was done.
He was sent home that day, and the hospital never followed up with his parents.
His parents rushed him back to the hospital two days later after his symptoms worsened. His condition deteriorated quickly and he died at 10.38pm.
Linton said she was satisfied there was an opportunity for an experienced clinician, such as Dr Siow, to have identified that Sandipan had a more serious health issue than a simple viral illness.
Siow told the inquiry she did not read the GP referral, instead relying on another doctor to distil the information to her.
She said with the benefit of hindsight she would have read the letter herself which might have alerted her to the fact the GP was concerned about sepsis.
Linton said Siow should have read the letter.
“This was more than a missed opportunity.”
WA Acting State Coroner Sarah Linton
“In those circumstances, I consider it was incumbent upon Dr Siow to inform herself personally of the contents of the GP letter, which would have alerted her to the recommendation that a blood test be performed,” she said.
Whether Dhar and his wife asked for blood tests at Joondalup was a point of contention during the inquest but Linton said she preferred Dhar’s evidence.
She did not make a finding about whether those requests for blood tests were made to Siow because there were no notes written and Siow recalled the events differently.
She found Siow considered doing a blood tests, but did not proceed because she was waiting for results of a urine test and after weighing the pros and cons deemed it unnecessary at the time because she thought Sandipan likely had viral tonsillitis.
Linton said she could not resolve the question of whether it was reasonable that a blood test did not happen because expert evidence from both sides differed as to what would have constituted reasonable care.
Linton found Dhar and his wife ultimately accepted Siow’s decisions on March 22.
She also made remarks about Sandipan’s discharge from the hospital and why there was no follow-up.
She referenced another near-miss case at Joondalup Health Campus around that period when a mother whose daughter had been bitten by a snake felt doctors weren’t taking her concerns seriously enough, so she took her to another hospital where her concerns were “proven correct”.
“The difference between this case and that one is that in the other case, the parent was not willing to trust the doctor’s advice, whereas unfortunately, in this case, Mr and Mrs Dhar placed more trust in the doctors’ opinion,” she said.
Linton found the Dhar family’s Indian cultural heritage likely played a role in the communication breakdown, with the non-confrontational demeanour mistaken for agreement with the plan devised by doctors.
Linton made six recommendations, including that JHC update and review its ED discharge and follow-up guidance and improve training for dealing with families from culturally and linguistically diverse backgrounds.
Hamish Hastie is WAtoday’s state political reporter and the winner of five WA Media Awards, including the 2023 Beck Prize for best political journalism.Connect via X or email.From our partners
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