Inquest into the Death of Tamar Jemima Sabbath Stitt
Deceased
Tamar Jemima Sabbath Stitt
Demographics
10y, female
Date of death
2009-11-12
Finding date
2014-10-09
Cause of death
Septic shock and multiple organ failure as complications of advanced metastatic hepatoblastoma
AI-generated summary
Tamar, a 10-year-old girl diagnosed with advanced metastatic hepatoblastoma in August 2009, died from septic shock and multiorgan failure in El Salvador on 12 November 2009. Her treating oncologist Dr A. at Princess Margaret Hospital recommended urgent chemotherapy using the SIOPEL 3 protocol, which offered approximately 50% long-term cure rate. Despite excellent communication by Dr A., clear medical advice, and consultation with other doctors, her parents chose to pursue natural therapies (red clay treatment) instead. A second opinion from Dr N. incorrectly advised that imaging showed tumour shrinkage, encouraging continued natural therapy delay. The parents took Tamar to El Salvador in early September 2009, avoiding court proceedings. After 6 weeks of untreated disease, Tamar deteriorated significantly with weight loss, paraplegia, and pleural effusion before hospitalisation in late October. While chemotherapy was commenced in El Salvador, her condition was too advanced. Likely preventable with early chemotherapy initiation in early September 2009. Clinical lessons include: proper imaging modality comparison, clear communication of cure rates, avoiding unsupported prognostic claims, and documentation of disagreements with parents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Delayed commencement of chemotherapy due to parental refusal
- Delay of approximately 7-8 weeks before appropriate treatment initiated in El Salvador
- Advanced stage of disease at presentation to El Salvador hospital
- Immunosuppression from chemotherapy in context of advanced disease
- Unsupported medical advice that tumour appeared smaller, encouraging continued natural therapy
- Lack of appropriate monitoring and medical assessment during natural therapy period
Coroner's recommendations
- Consideration should be given to referring Dr N.'s conduct to the Australian Health Practitioners Regulation Authority (AHPRA) pursuant to section 50 of the Coroners Act 1996, particularly regarding unsupported prognostic claims
- Treating oncologists should ensure parents receive clear, objective, and well-documented advice regarding cure rates and treatment urgency
- When different imaging modalities are used for tumour assessment, clinicians must clearly explain the limitations and risks of direct comparison between modalities
- Parents using natural therapies concurrently with conventional treatment should be encouraged to fully disclose all therapies so treating doctors can assess potential interactions and toxicity
- Clinical ethics committees should be offered early to families with treatment disagreements to provide objective forum for discussion
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