Father of Perth toddler who died with undiagnosed leukaemia welcomes coronial inquest

The father of a one-year-old boy suffering from undiagnosed leukaemia who died in Joondalup Health Campus in March says he looks forward to a coronial inquest delivering “justice” for his son.

The WA coroner’s office confirmed it will launch an inquest into the death of Sandipan Dhar on the same day an independent review of his care at the northern suburbs hospital was handed to his father Sanjoy and mother Saraswati.

Sanjoy Dhar speaking to media on November 5.Credit: Nine News

Sandipan’s parents pleaded with staff at both Joondalup Health Campus and the Key Largo Medical Centre in Clarkson for blood tests to help identify why their son had a persistent fever, which could have identified his blood cancer before he died on March 24.

Sanjoy said he was not 100 per cent satisfied with the report commissioned by Joondalup Health Campus operator Ramsay Health Care, but he looked forward to a more comprehensive inquest by the state coroner which would look at the actions of the GPs before Sandipan was taken to hospital, as well as the clinicians at Joondalup.

“I left my soul ... in Joondalup, so I do not have any emotion remaining. I just want [the judgment],” he said.

“I understand that justice delayed is not delivered justice.”

Sandipan Dhar died aged 21 months.

The 33-page report released today cleared hospital staff and said it was reasonable that Sandipan was not given a blood test at the time.

It was handed to the family the same day another report into the death of an unborn baby at the same hospital, on the same weekend Sandipan died, was given to that family.

Sandipan was just shy of his second birthday when his parents rushed him to the hospital with a high fever that would not settle.

He died in the hospital on March 24, more than one month after he began suffering a long-running mild fever.

His parents claimed they took their son to the GP four times and the hospital twice before a hospital X-ray revealed he had pneumonia.

By that stage, it was too late to save his life and a post-mortem revealed the boy was also suffering from undiagnosed leukemia.

Sandipan’s parents said they requested blood tests at both at the Key Largo Medical Centre, where he was first taken, and at Joondalup Health Campus.

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.

The parents have been waiting months for a second independent inquiry, which was handed to them on Tuesday and backed hospital staff actions.

“Both reviews found that Sandipan Dhar’s clinical care was of an acceptable standard and that it was reasonable clinical staff did not order blood tests during the toddler’s first presentation to JHC ED,” it said.

Ramsay Health Care WA manager Dr Shane Kelly said today would be “extraordinarily difficult” for the two grieving families who have lost children.

But the review into Sandipan’s care at the hospital found it had been was entirely acceptable and the decision not to take the blood test on his first admission was reasonable, Kelly said.

Sandipan’s death bore similarities to the death of seven-year-old Morley girl Aishwarya Aswath at Perth Children’s Hospital in 2021, which resulted in the Aishwarya’s CARE call system for parents to escalate their concerns when they felt they were not being listened to in WA hospitals.

That system was in place at Joondalup when Sandipan presented there.

Asked if it was concerning parents were still struggling to be heard given the tragedy of Aishwarya Aswath’s death three years ago, Health Minister Amber-Jade Sanderson said she was disappointed Sandipan’s parents’ concerns weren’t acknowledged – but noted this was conceded in the review.

Sanderson also backed the review’s findings that it was reasonable that the hospital did not order a blood test.

“What the review finds is that based on the information that they had in front of them, that it was appropriate to those clinicians to take that decisions that they did,” she said.

However, Sanderson said the actions of Key Largo Medical Centre in Clarkson needed to be examined, which had not happened because the centre declined to take part in the review.

Sandiplan was suffering from undiagnosed leukeamia.

She said both herself and the family had written to Key Largo requesting a meeting, which had been declined.

“They have declined all of those on the grounds that there’s an Australian Health Practitioner Regulation Agency investigation under way, and I don’t think that’s a reasonable response,” she said.

“There’s nothing stopping them from sitting down and listening to the family.”

Key Largo Medical Centre was approached for comment.

The report made nine recommendations to Joondalup Health Campus and one external recommendation, which was to support a coronial inquest into Sandipan’s death and review his care before he presented to hospital.

The hospital has committed to implementing all nine recommendations aimed at its own operations.

These include improving communication and relationships with staff and visitors to the ED; enhancing the function of the paediatric pod in the ED, including more staff and more skills to meet the increased demand of the hospital and increasing beds at the hospital.

The report also recommended the hospital review its complaints and patient liaison services.

“This report is very clear that we need to empower parents, mums and dads, to express their concerns, and we need to enable our staff to respond to those concerns, so parents can feel that they’re part of the care team,” Kelly said.

“I want to emphasise better communication with parents about concerns they have in relation to their children’s care is incredibly important, and we’re enhancing training in empowering our staff.

“This report takes us forward, and implementing the recommendations is what will make the difference to ensure we deliver the care that our community expects and deserves.”

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