Inquest into the Death of Sandipan DHAR

1y · Male·Complications of acute lymphoblastic leukaemia

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.