WA Coroner finds one-year-old boy Sandipan Dhar’s death was preventable after doctors failed to give blood test
A young child’s death from leukemia was “highly preventable” after doctors missed opportunities to diagnose the disease, a coroner has found.
Sandipan Dhar was 21 months old when he died suddenly at the Joondalup Health Campus in Perth’s north, after his parents were denied repeated requests for blood tests despite the boy battling a long-standing fever.
Deputy State Coroner Sarah Linton found that if Sandipan had been diagnosed it would have opened up the opportunity for him to receive treatment for leukemia.
The coroner found that Sandipan would likely have recovered from his illness had a blood test been performed, but the opportunity to diagnose and treat the child was missed.
Ms Linton said if blood tests had been carried out the child’s leukemia would have been detected and with treatment he was likely to survive.
“His death was therefore extremely preventable,” he said.
The inquest was told Sandipan’s parents took him to the GP several times after he developed a fever after being vaccinated.
The child was treated for tonsillitis after the doctor noticed the inflammation, but when his temperature rose above 38°C during one of the visits, he was referred to the hospital for further examination and blood tests.
His family took him directly to Joondalup Health Campus on March 22, but his request for a blood test was ignored.
The inquest was told that a senior doctor at the hospital did not read the referral letter from the GP and relied on a junior doctor’s analysis.
Sandipan was treated for a viral illness and sent home, but was rushed back to the hospital two days later when his parents noticed his condition was worsening.
He died in hospital later that night.
“He was always healthy and well until the last few weeks before his death,” Ms Linton said.
“Knowing that Sandipan had a disease that was likely treatable had it been diagnosed in time raised important questions about how we can ensure similar cases are not missed in the future.
“His death has led to the implementation of significant changes to the Joondalup Health Campus to make it safer for pediatric patients and their families.”
