Inquest into the Death of Tamar Jemima Sabbath Stitt

10y · Female·Septic shock and multiple organ failure as complications of advanced metastatic hepatoblastoma

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.