Inquest into the Death of Child SJC (Name Subject to Suppression Order)

2y · Female·Complications relating to metastatic neuroblastoma

A 2-year-old girl with Stage IV high-risk neuroblastoma (N-myc positive) received intensive, world-class treatment including chemotherapy, surgery, mega-therapy, radiotherapy, and biotherapy at Princess Margaret Hospital. She initially achieved remission but relapsed after 7 months. Dinutuximab immunotherapy, considered standard care, was unavailable due to global supply shortages until approval was obtained in July 2017—one week before relapse occurred. Despite subsequent treatment with Dinutuximab Beta, tumours continued to progress. The child died from metastatic neuroblastoma complications while under state care and receiving palliative hospice services. The coroner found medical care was of high standard and that earlier Dinutuximab access would likely not have altered the outcome given the aggressive disease course and poor response to immunotherapy at relapse.