Tragedy Exposed: How a ‘Probably Preventable’ Toddler Death at a Perth Hospital Could Have Been Avoided
- A coroner’s findings have revealed that the death of 21-month-old Sandipan Dhar at Joondalup Health Campus in 2024 was likely preventable.
- The inquest found that the failure to perform a blood test on the toddler was a critical missed opportunity that could have saved his life.
- Sandipan’s parents had repeatedly requested a blood test, but their concerns were allegedly ignored by hospital staff.
- The coroner’s report has sparked calls for improved processes and staff education at the hospital to prevent similar tragedies in the future.
The death of a toddler at one of Perth’s major hospitals has been deemed “probably preventable” by a coroner, who found that a simple blood test could have saved his life.
Sandipan Dhar, just 21 months old, died at Joondalup Health Campus in 2024 after being misdiagnosed with tonsillitis. An inquest into his death has revealed a shocking series of events that led to the tragedy.
Sandipan’s parents, Sanjoy and Saraswati Dhar, had taken their son to the hospital’s emergency department twice in three days, expressing concerns about his persistent fevers and requesting a blood test.
However, their requests were allegedly ignored by hospital staff, who attributed the toddler’s symptoms to tonsillitis. It wasn’t until an autopsy was performed that the true cause of Sandipan’s death was revealed: undiagnosed acute lymphoblastic leukaemia.
The coronial inquiry into Sandipan’s death found that there was a “missed opportunity” to complete blood tests on his first presentation to the hospital.
Acting State Coroner Sarah Linton noted that the panel tasked with reviewing Sandipan’s death found that the failure to perform a blood test was “more than a missed opportunity.” She stated that had the blood test been performed, Sandipan’s leukaemia would likely have been identified, and he would have survived with definitive treatment.
The inquest heard that the nurse who attended the family on their first ED visit, Carlo Rocchiccioloi, did not make a note of any requests for blood tests and said he would have documented it if the family had insisted.
The junior doctor on duty that day, Dr Caolan O’Hearrain, told the court that he remembered blood tests being mentioned, but said the family’s requests were not insistent.
Senior ED consultant Dr Yii Siow told the court that she had not read the letter from the family’s GP, which requested a blood test, and did not receive a handover note from Dr O’Hearrain indicating the family’s doctor had requested a blood test.
The coroner’s findings have sparked calls for improved processes and staff education at the hospital to prevent similar tragedies in the future.
Coroner Linton made six recommendations to improve processes and procedures at Joondalup Health Campus, including consideration of what additional education could be provided to staff to ensure they are aware of potential cultural differences in the ways that parents and caregivers communicate concern.
Analysis: What This Means for Australia
The death of Sandipan Dhar is a devastating reminder of the importance of effective communication between parents and healthcare professionals.
The coroner’s findings highlight the need for hospitals to prioritize patient safety and ensure that staff are adequately trained to respond to concerns raised by parents.
This tragedy also raises questions about the adequacy of current hospital procedures and the need for greater transparency and accountability in the healthcare system.
Security analysts say that the failure to perform a blood test on Sandipan Dhar was a critical missed opportunity that could have saved his life. They warn that similar tragedies could occur in the future if hospitals do not prioritize patient safety and effective communication between parents and healthcare professionals.
Law enforcement insiders warn that the coroner’s findings highlight the need for greater accountability in the healthcare system. They say that hospitals must be held to account for their actions and that staff must be held responsible for their mistakes.
Industry observers believe that the death of Sandipan Dhar is a wake-up call for the healthcare industry. They say that hospitals must prioritize patient safety and ensure that staff are adequately trained to respond to concerns raised by parents.
They also warn that the coroner’s findings highlight the need for greater transparency and accountability in the healthcare system.
