Coronial
WAhospital

Inquest into the Death of Sandipan DHAR

Deceased

Sandipan DHAR

Demographics

1y, male

Coroner

Acting State Coroner Linton

Date of death

2024-03-24

Finding date

2026-03-27

Cause of death

Complications of acute lymphoblastic leukaemia

AI-generated summary

A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GPs, and carried a referral letter recommending blood tests and sepsis screening. The ED consultant did not order blood tests, instead waiting for urine and PCR test results. The patient left without the urine sample being obtained. If blood tests had been performed on 22 March, the leukaemia would likely have been identified with good survival outcomes. Key failures included: non-recognition of significant parental concern (possibly influenced by cultural factors), failure to read the GP referral letter, failure to appropriately follow up when the family left early, and inadequate safety netting. Communication barriers between the culturally and linguistically diverse family and clinical staff contributed to concerns not being effectively heard.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinepaediatricshaematologygeneral practice

Error types

diagnosticcommunicationdelay

Drugs involved

paracetamolibuprofenpenicillin

Clinical conditions

acute lymphoblastic leukaemiasepsispneumoniatonsillitisfever

Procedures

blood testurine analysischest X-rayrespiratory swab

Contributing factors

  • Failure to order blood tests despite GP recommendation for sepsis screening
  • Non-recognition or misinterpretation of significant parental concern
  • Emergency consultant did not read GP referral letter personally
  • Communication barriers due to cultural and linguistic differences not adequately addressed
  • Failure to follow up when family left ED before completion of planned investigations
  • Inadequate safety netting and discharge instructions
  • Tachycardia and prolonged intermittent fever not recognised as sufficient indication for further investigation

Coroner's recommendations

  1. JHC should review and update ED discharge and follow-up documentation to avoid ambiguous time-based advice, preferring time-window descriptors like '24-48 hours' or 'early next week' over specific dates, with audit of paediatric ED discharges within six months
  2. JHC should reinforce through education and documentation the importance of clearly distinguishing 'infection' from 'sepsis' in family communications, with plain-language explanations of how tests inform next steps and safety netting information including red flags for early return
  3. JHC should maintain and resource the Paediatric Rapid Access Review Clinic and evaluate its effectiveness
  4. JHC should maintain its post-departure text-message/call-back protocol for patients who leave before planned investigations are completed, with periodic evaluation at six and twelve months
  5. JHC should review and confirm paediatric-specific triggers exist for contacting patients who did not wait or left after treatment commenced, particularly where investigations were not completed, with six-month compliance audit
  6. JHC should provide additional education to clinical staff, particularly ED paediatric staff, on cultural differences in how parents communicate concern, with CALD-aware triggers in safety netting to offer interpreter and/or social work support, and include such cases in six-month audit of paediatric ED discharges
Full text
Official source Archived copy

Related cases from WA

WA2026-03-26

Inquest into the Death of Brian John KEALY

42y · Male·Ligature compression of the neck (hanging)

Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…

psychiatrygeneral practicediagnosticcommunicationolanzapine
WAcommunity2025-12-09

Inquest into the Suspected Death of Eric Donald BRANDRICK

47y · Male·unascertained

Eric Donald Brandrick, a 47-year-old man with significant disability from a right thalamic intracerebral haemorrhage stroke in September 1988, was last confirmed alive on 31 December 1989 at Royal Perth Hospital Emergenc…

rehabilitation medicineneurologydiagnosticcommunicationparacetamol
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

Cleveland Keith Dodd, aged 16, died on 19 October 2023 from complications of ligature compression of the neck (hanging) while in custody at Unit 18, a youth detention facility within Casuarina Prison, Western Australia. …

psychiatryemergency medicinediagnosticcommunication

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.