Coroner Finds "Missed Opportunity" in Preventable Death of Toddler at Perth Hospital

An inquest into the death of a 21-month-old boy at a Perth hospital has found there was a "missed opportunity" to complete a blood test and that his death was "probably preventable."

Sandipan Dhar died at Joondalup Health Campus on March 24, 2024. An autopsy later determined the cause of death was undiagnosed acute lymphoblastic leukaemia.

Timeline of Events

The boy's parents had taken him to the hospital's emergency department twice in the three days prior to his death. They stated they had requested a blood test during these visits.

Coronial Findings

Acting State Coroner Sarah Linton concluded the death was "probably preventable." She found a senior emergency department consultant, Dr. Yii Siow, had not read a letter from the family's general practitioner which recommended a blood test, and was not made aware of the request in a handover note.

The coroner stated it was "incumbent upon Dr Siow to inform herself personally of the contents of the GP letter."

Family and Institutional Responses

Sandipan's father, Sanjoy Dhar, said the inquest vindicated the family's claims that their pleas were ignored. He stated the clinicians involved should be penalized and that there is a lack of accountability in the system.

James Cafaro, state manager for hospital operator Ramsay Health Care, said all involved clinicians had been referred to the Australian Health Practitioner Regulation Agency (AHPRA) for review. AHPRA found the care provided was appropriate and imposed no conditions on the clinicians.

Cafaro stated "significant changes" have been implemented since the death, including strengthened discharge safety measures and additional staff education focused on pediatric care. The hospital stated it would implement all recommendations from the coroner.

Broader Calls for Change

Family advocate Suresh Rajan called for the coroner's recommendations to be implemented more broadly across the state's health system. He also questioned whether Ramsay Health Care should continue operating the hospital.

Background and Recommendations

The family had waited more than two years for the coroner's findings. The coroner's recommendations include reviewing the hospital's emergency department procedures for discharging patients and ensuring appropriate follow-up is provided.