The death of 21-month-old Sandipan Dhar at Joondalup Health Campus has been described as “probably preventable”, with a coroner finding a critical opportunity to diagnose his illness was missed.

It is reported that Sandipan died in March 2024 after being taken to hospital with a persistent fever that had lasted for weeks. His parents had sought medical attention multiple times and were referred to the emergency department by a GP, who recommended blood and urine tests.

However, the coroner found that no blood test was carried out during the hospital visit on March 22, when Sandipan was assessed and later discharged.

In findings prepared last month, the coroner concluded that if the requested blood test had been performed, the child’s acute leukaemia would likely have been detected in time for treatment.

The report states Sandipan “would have survived with definitive treatment” had the diagnosis been made earlier.

Two days after being sent home, Sandipan’s condition worsened and he was rushed back to hospital, where he died on March 24. An autopsy later confirmed undiagnosed acute leukaemia.

As per 7News, the coroner noted the case involved more than a single missed step, describing it as a lost opportunity to intervene during a critical window.

Sandipan’s parents had raised concerns about his ongoing fever and had requested further testing, including blood work. Evidence about those requests was examined during the coronial inquest.

The coroner has made six recommendations following the investigation, including measures aimed at improving the assessment and treatment of children in emergency departments at the facility.

The findings are expected to be released publicly in full.

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