A coronial inquest into the death of 21-month-old Sandipan Dhar from an undiagnosed acute blastoma leukemia will look at whether a blood test in the days before could have prevented his death.
Sandipan died at Ramsay Health Care’s Joondalup Health Campus on March 24, 2024 due to complications from the common blood cancer, more than a month after he started suffering a long-running mild fever.
Sandipan Dhar died aged 21 months.
Sandipan’s family said they requested blood tests at both at the Key Largo Medical Centre in Clarkson, where he was first taken, and at Joondalup Health Campus.
WA’s health regulator and internal hospital inquiries have cleared the medical centre GPs and hospital staff of any wrongdoing.
But on Tuesday, Deputy State Coroner Sarah Linton said at the heart of the inquest was whether a blood test on the Friday before his death would have changed the course of Sandipan’s condition, or whether the hospital should have kept him admitted on the family’s second-last visit on March 22.
Sandipan’s father Sanjoy teared up during opening remarks after standing up and urging the inquest to get to the truth of what happened to his son.
“We only have the expectation that the truth should come,” he said.
Counsel assisting the coroner Will Stops delivered his opening address while a looping slideshow of images of Sandipan was played to the court.
Sandipan’s mother Saraswati took him to Key Largo Medical Centre on February 15 after he injured his leg jumping from a bed. He had an X-ray, which deemed him fine, and he returned on February 19 when he was also given his scheduled immunisations.
Three weeks later, his parents took him back to Key Largo after a week of recurrent fevers.
Stops told the court GP Dr Chinniah Prabhakar found the boy’s throat was red, but he otherwise presented as normal. No medication was prescribed, and Sandipan’s parents were told to come back if their concerns continued.
Six days later on March 20, Sandipan’s parents took him back to the clinic, where GP Dr Sanjeev Rana noted he had pus on his tonsils and a mildly inflamed right ear, but his temperature was only slightly raised at 37.3 degrees after having paracetamol.
Rana found Sandipan’s symptoms suggested tonsilitis and suggested he be treated with antibiotics and paracetamol, and return in two days.
He reviewed Sandipan again on March 22 and found his symptoms were persisting, and his temperature was 38.3 degrees.
Stops told the court Sandipan’s parents requested a blood test, but Rana’s preference was to refer him to hospital, where they could do a septic screen.
“Dr Rana suggested the need for blood tests and urine tests and consideration of IV antibiotics if he met the criteria,” Stops said.
Stops told the court Sandipan was triaged as “urgent” at Joondalup Health Campus, and while the ED was appropriately staffed at the time, there were no beds immediately available for new admissions.
The court was told the hospital’s residential medical officer, Dr Caolan O’Hearrain, noted Sandipan’s symptoms and found he was distressed and had a heart rate of 170 beats per minute.
Stops said O’Hearrain formed a preliminary diagnosis of viral tonsilitis and presented his case to the supervising ED consultant doctor, Dr Yii Siow, who saw Sandipan twice for formal assessment.
The plan at that point was to conduct urine tests and swab for viral infections.
Stops told the court there were conflicting reports as to whether Sandipan’s parents specifically requested blood tests in addition to the GP letter.
“Sandipan’s parents recall they asked for blood tests to be taken on at least three occasions, after they suspected there was something serious at play,” he said.
“However, none of the Joondalup Health Campus staff recall the parents requesting blood tests at any stage during the presentation.
“Medical staff will say they did turn their mind to blood testing and decided not to collect blood samples based on the clinical assessment.
“Again, this decision, or the rationale for this decision, is not documented or mentioned anywhere in the medical records.
“There is no reference in the notes to the blood tests that were suggested by
the GP being considered.”
Sandipan and his parents left the hospital at 7pm after he had settled.
Stops told the court there was conflicting evidence as to whether the family chose to leave the ED against advice, or whether they were told to leave, with no notes to clarify the situation.
Sandipan was rushed 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.
Stops told the court acute lymphoblastic leukaemia represented 55 per cent of all blood cancer diagnoses in children up to 14 years old.
“The incidence is highest in children ages two to four, and it is more common in boys, so Sandipan fell within the most common demographic,” he said.
Stops cited a Joondalup Health Campus review of the incident that found the identification of the blood cancer would have dramatically changed the course of Sandipan’s treatment.
An initial inquiry, known as a Severity Assessment Code 1 inquiry, found there was a missed opportunity to get his blood tested at his first presentation at hospital.
A review commissioned by Ramsay backed the hospital’s actions and cleared medical staff of any wrongdoing.
Key Largo Medical Centre has so far not met with the parents.
WAtoday revealed in March that Labor’s Riverton MP Jagadish Krishnan owns a 10 per cent share in Key Largo Medical Centre.
An Australian Health Practitioner Regulation Agency investigation cleared the GPs of any wrongdoing in a December report.
Stops told the court no one hearing of Sandipan’s case would fail to be touched by the profound grief of his family and their desire for answers.
“They want to be reassured that lessons have been learned. It is hoped this inquest will assist in their quest,” he said.
The inquest is scheduled for three days of hearings.
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