Overview
- The coroner found a blood test on March 22, 2024 would likely have identified 21‑month‑old Sandipan Dhar’s leukaemia and prevented his death.
- Sandipan died at Joondalup Health Campus on March 24 from undiagnosed acute leukaemia, a childhood blood cancer often visible on a routine blood count.
- Relying on an impression that the child looked well, the supervising ED doctor did not read the GP’s referral calling for blood tests and chose not to order them while waiting for urine results, which the coroner criticised.
- Key details remain disputed because the parents say they requested blood tests several times while hospital staff contest that account, and the coroner did not decide if the overall care met accepted standards due to conflicting expert evidence.
- The report issues six recommendations for Joondalup’s ED that tighten discharge and follow-up rules and add training for clearer communication with culturally and linguistically diverse families after a noted breakdown with the Dhars.