Coroner rules toddler’s leukaemia death at Perth hospital was preventable due to missed blood tests
Consensus Summary
A coronial inquest into the death of 21-month-old Sandipan Dhar at Joondalup Health Campus in Perth ruled his death from undiagnosed acute leukaemia was preventable due to missed opportunities for a blood test. Sandipan’s parents had taken him to the hospital on March 22, 2024, after weeks of fever following vaccinations, but their requests for testing were ignored by staff, including a senior doctor who failed to review a GP referral letter. The coroner found that if blood tests had been performed during his first visit, his leukaemia would likely have been detected in time for treatment, and he would have survived. Sandipan’s condition deteriorated rapidly, and he died two days later on March 24, 2024. The inquest highlighted systemic failures, including poor communication between junior and senior doctors and inadequate documentation of parental concerns. Both sources agree the incident has prompted reforms at the hospital to prevent similar cases in the future.
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Key details reported by multiple sources:
- Sandipan Dhar was 21 months old when he died at Joondalup Health Campus, Perth, on March 24, 2024, from undiagnosed acute leukaemia
- Sandipan’s parents took him to Joondalup Health Campus on March 22, 2024, and requested a blood test, which was ignored by hospital staff
- Acting State Coroner Sarah Linton ruled Sandipan’s death was ‘highly preventable’ (NEWSCOMAU) or ‘probably preventable’ (ABC) if a blood test had been performed on March 22, 2024
- Sandipan had a fever for about three weeks after receiving routine vaccinations in March 2024, prompting his parents to seek medical attention
- A senior doctor at Joondalup Health Campus (Dr Yii Siow) failed to read a referral letter from the family’s GP (Dr Sanjeev Rana) requesting a blood test
- Sandipan was treated for a viral illness and sent home on March 22, 2024, but died in hospital two days later on March 24, 2024
- The inquest findings were handed down on April 18, 2026, more than two years after Sandipan’s death
Points of Difference
Details reported by only one source:
- Coroner Sarah Linton stated Sandipan would ‘most likely have survived his illness’ with timely treatment, framing the missed diagnosis as a ‘missed opportunity’
- The coroner noted Sandipan’s parents took him to their GP multiple times after he developed a fever following vaccination, with tonsillitis initially diagnosed
- The inquest highlighted that a nurse (Carlo Rocchiccioloi) did not document the family’s blood test request, claiming they were not insistent
- Changes have already been implemented at Joondalup Health Campus to improve paediatric patient safety following the incident
- The coroner described the missed blood test as ‘more than a missed opportunity’ in her findings
- Junior doctor Dr Caolan O’Hearrain testified he remembered blood tests being mentioned but said the family’s requests were ‘not insistent’
- Senior ED consultant Dr Yii Siow stated she was not concerned because Sandipan ‘looked well’ and did not receive a handover note about the blood test request
Contradictions
Conflicting information between sources:
- NEWSCOMAU describes the coroner’s ruling as ‘highly preventable,’ while ABC uses the term ‘probably preventable’ for the same finding
- NEWSCOMAU states the coroner found Sandipan would ‘most likely have survived,’ while ABC does not include this exact phrasing in its summary of the ruling
Source Articles
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