Inquest into the Death of Sandipan DHAR
Delivered on: 27 March 2026
Delivered at: Perth
Finding of: Acting State Coroner Linton
Recommendations:
Recommendation 1
I recommend that JHC review and update its ED discharge and follow-up documentation and guidance so that time-based advice is conveyed with sufficient clarity to avoid misinterpretation. Where a specific date is not clinically indicated, staff should prefer time-window descriptors (e.g., "within 24- 48 hours" or "early next week") and ensure that the verbal advice and the discharge summary use consistent wording. JHC should audit a sample of paediatric ED discharges within six months to confirm consistent use.
Recommendation 2
I recommend that JHC reinforce, through routine clinician education and documentation guidance, the importance of clearly distinguishing "infection" from "sepsis" in family communications and discharge information, including a short plain-language explainer on how tests (e.g., urinalysis, bloods) inform next steps and information as to signs to look for that might prompt early return, as part of safety netting, particularly in paediatric cases.
Recommendation 3
I recommend that JHC maintain and resource the Paediatric Rapid Access Review Clinic, and that its effectiveness be evaluated (e.g., time to review after ED discharge; unplanned ED re-presentation within 72 hours and 7 days; unplanned admission) to guide future planning and resourcing.
Recommendation 4
I recommend that JHC maintain its post-departure text-message/call-back protocol for patients who leave before planned investigations or treatment are completed, and periodically evaluate its operation (e.g., contact rate, time-to-contact, outcomes of contact) at six and twelve months, using results to refine triggers and resourcing.
Recommendation 5
I recommend that JHC review and confirm that paediatric-specific triggers exist and are consistently applied to initiate same-day contact where a child did not wait (DNW) or left after treatment commenced (LATC) and either (a) left before completion of an investigation central to the plan (e.g., urinalysis in a prolonged-fever assessment), or (b) other risk indicators persist. A short compliance audit at six months is suggested.
Recommendation 6
I recommend that JHC consider what additional education can be provided to all clinical staff at JHC, with a particular focus on ED staff providing paediatric care, to ensure they are aware of potential cultural differences in the ways that parents and caregivers communicate parental concern. Further, with the benefit of that training, there should be a CALO-aware trigger within the ED safety netting to ensure that where language/cultural differences are identified, staff offer interpreter and/or social work support and record the offer and any assistance provided in the clinical record. Any such cases should be included in the six month audit of paediatric ED discharges to monitor whether it is assisting CALO families to better engage with clinical staff in the ED, or whether more supports are required for CALO families.
Orders/Rules: N/A
Suppression Order: N/A
Summary:
Sandipan Dhar died on 24 March 2024 at Joondalup Health Campus (JHC). He died from complications of an infection on a background of undiagnosed acute lymphoblastic leukaemia. The Coroner found his death occurred by way of natural causes. He was 21 months old.
The Coroner observed that Sandipan had developed a rare, but not unknown form of childhood leukaemia. Diagnosis of this illness at an early stage can be difficult, as the symptoms are similar to many other, non-life-threatening, viral illnesses. However, there were features of Sandipan's presentation that could and should have alerted the clinicians who were treating him in the days prior to his death to the possibility that his likely viral illness of tonsilitis may have become complicated by bacterial sepsis. This might have prompted a blood test, or alternatively further monitoring or early follow-up. If a blood test had been performed at the first hospital presentation on 22 March 2024, as suggested in a GP referral letter, the Coroner was satisfied to a high degree of probability that Sandipan's leukaemia would have been identified and this would have resulted in further investigations and treatment that may have prevented his death. However, the Coroner accepted that the decision as to whether to perform a blood test on that date was finely balanced and reasonable practitioners differ as to whether they would have ordered blood testing in the circumstances of the presentation on that date.
The Coroner also considered the issue of culturally and linguistically diverse (CALO) patients and families and whether this may have impacted upon good communication between Sandipan's parents and the treating health practitioners.
Although difficult to make recommendations tailored to what changes have already been implemented, the Coroner made 6 recommendations to build upon the changes already in place or being progressed independently of the coronial process.
Catch Words: Child Death : Medical Treatment : Natural Causes : Acute Lymphoblastic Leukaemia (ALL) : Culturally and Linguistically Diverse (CALO) Patients and Carers
Last updated: 22 April 2026