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The death of bubbly 21-month-old Sandipan Dhar in 2024 shook the health establishment in Western Australia, and now his family’s fight to ensure their son will not become just another statistic is set to culminate with the long-awaited release of the findings of a coronial inquest.
Despite being plunged into a deep grief after the loss of his son from a curable blood cancer so early in his life, Sandipan’s father Sanjoy Dhar has remained steadfast his son’s death will result in a better health system for other families.
“We will continue to pursue every lawful avenue available within the Australian system,” Dhar told this masthead ahead of the imminent release of the coroner’s report.
“This is not about politics. It is about transparency, accountability and systemic reform. Australia is a democracy, and public institutions are ultimately accountable to the community.
“I have spoken with the state health minister, the state opposition leader, the shadow health minister, the Greens’ health spokesperson and several members of Parliament. Across party lines, I have received assurances of support for meaningful reform.
“I remain cautiously hopeful. If this tragedy results in stronger oversight, independent review mechanisms and enforceable accountability standards, then at least some meaningful improvement may come from an otherwise devastating loss.
“This is not the end. It is the beginning of a call for systemic change — so that no other family has to endure what we have endured.”
The days before
Sandipan died at Ramsay Health Care’s Joondalup Health Campus on March 24, 2024 due to complications from undiagnosed acute blastoma leukemia, a common and curable cancer, more than a month after he started suffering a long-running mild fever.
Sandipan’s mother Saraswati took him to Key Largo Medical Centre on February 15 that year after he injured his leg jumping from a bed. He was deemed fine, and returned on February 19 when he was also given his scheduled immunisations.
After a week of recurrent fevers, Sandipan’s parents took him back to Key Largo on March 20, where a GP prescribed some paracetamol and antibiotics after they found he had a mildly elevated temperature, pus on his tonsils, and a mildly inflamed right ear.
Two days later, his parents returned to Key Largo with persisting symptoms and 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.
It was during this visit that Dhar said his family requested a blood test at least three times, but this was disputed by Joondalup Health Campus operator Ramsay Healthcare and the supervising ED consultant doctor at the time, Dr Yii Siow, during the coronial inquest in May last year.
Sandipan was sent home that day, but his parents rushed him back to hospital two days later on March 24 where his condition deteriorated quickly. He died at 10.38pm.
During resuscitation attempts, blood test results identified leukaemia, which was confirmed during a post-mortem.
Dhar was forced to leave the inquest last year during Ramsay’s evidence and accused the hospital of lying about his requests for blood tests.
‘Hope and anxiety’
WA’s health regulator and internal hospital inquiries cleared the medical centre GPs and hospital staff of any wrongdoing, which has angered Dhar, who said he was relieved when he found out the coroner would look into his son’s death in late 2024.
Dhar said the build up to the inquest findings being released had been emotionally difficult for his family, but ultimately he hoped it led to change.
“The inquest brings both hope and anxiety — hope for clarity and transparency, and for findings that are firmly grounded in evidence,” he said.
At the heart of Deputy State Coroner Sarah Linton’s inquiry was whether the blood test could and should have been done in the days before Sandipan’s death.
Dhar said he hoped the coroner looked at mandatory blood tests where children present multiple times at ED’s in a short period, parents report worsening symptoms, or when the symptoms are unexplained or nonspecific.
He also called for parental concern to be considered a clinical risk factor in hospitals, mandatory notes of parental concern during paediatric assessments, and clear escalation pathways when symptoms persist after patients are discharged.
Dhar also wants improvements in the review processes into medical incidents like his son’s – known as SAC1 reports – as well as improved independence in investigations into serious incidents and better communications with families.
“Accountability and patient safety standards must be consistent across both public and private healthcare systems,” he said.
“We hold firmly to the coroner’s commitment that Sandipan will not remain just another number within the WA health system. As his family, we cannot allow his life to be reduced to a statistic.”
Dhar also wants the state government to review its contract with Ramsay Health, or at least improve its oversight of private contractors running WA public hospitals.
“In other Australian jurisdictions, including New South Wales, governments have intervened in private hospital arrangements following serious concerns and transitioned facilities back into public management,” he said.
“As his family, we cannot allow his life to be reduced to a statistic”
Sanjoy Dhar
“We believe the WA government should objectively examine whether the current contractual and regulatory structure remains appropriate, and whether stronger public oversight — including potential structural reform — is necessary in the interests of patient safety.”
Ramsay Healthcare chief executive Natalie Davis the company sought to learn from any incident in its hospitals, and had done so in this case.
“We await the coroner’s findings, and we will continue to implement any recommendations that are recommended by the coroner,” she said.
WA Health Minister Meredith Hammat said she understood Dhar’s concerns, and she wanted to ensure care at WA hospitals met community expectations.
“We’re always looking at how getting the performance that we need, whether that’s hospitals that are run by the state, or whether that’s like Ramsey, where there is a public-private partnership for the provision of those services,” she said.
Hammat said the government would implement any findings in the report.
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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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