A Father’s Fight for Systemic Change After Tragic Loss
The devastating loss of 21-month-old Sandipan Dhar in 2024 sent shockwaves through Western Australia’s health community. Now, his family’s unwavering advocacy for a better healthcare system, spurred by their son’s preventable death from a curable blood cancer, is poised to gain momentum with the impending release of a coronial inquest’s findings.
Sandipan’s father, Sanjoy Dhar, despite the profound grief of losing his young son, has remained resolutely committed to ensuring his son’s death serves as a catalyst for meaningful reform. “We will continue to pursue every lawful avenue available within the Australian system,” Dhar stated, expressing his determination ahead of the coroner’s report. He emphasised that his pursuit is not about politics, but rather about fostering transparency, accountability, and systemic improvements. “Australia is a democracy, and public institutions are ultimately accountable to the community,” he asserted.
Dhar has actively engaged with key political figures, including the state health minister, the opposition leader, the shadow health minister, and parliamentary members. He reports receiving bipartisan assurances of support for significant reforms. “I remain cautiously hopeful,” Dhar commented. “If this tragedy results in stronger oversight, independent review mechanisms, and enforceable accountability standards, then at least some meaningful improvement may come from an otherwise devastating loss. This is not the end. It is the beginning of a call for systemic change — so that no other family has to endure what we have endured.”
The Crucial Days Leading Up to Sandipan’s Death
Sandipan passed away at Ramsay Health Care’s Joondalup Health Campus on March 24, 2024, succumbing to complications arising from undiagnosed acute blastoma leukemia. This form of leukemia is common and treatable, yet Sandipan’s condition went undetected for over a month, despite his parents seeking medical attention for a persistent, mild fever.
The sequence of events began on February 15, 2024, when Sandipan’s mother, Saraswati, took him to the Key Largo Medical Centre after he sustained a leg injury while jumping from a bed. He was initially deemed to be fine. A subsequent visit on February 19, for scheduled immunisations, also found him well.
However, after a week of recurring fevers, Sandipan’s parents returned to Key Largo on March 20. A general practitioner diagnosed a mildly elevated temperature, pus on his tonsils, and a slightly inflamed right ear, prescribing paracetamol and antibiotics.
Two days later, on March 22, his parents sought further medical advice at Key Largo due to the persistence of his symptoms and a temperature of 38.3 degrees Celsius. At this point, the parents requested a blood test. They were subsequently directed to Joondalup Health Campus, carrying a referral letter from the GP recommending both urine and blood tests.
It was during this visit to Joondalup Health Campus, according to Dhar, that his family requested a blood test on at least three separate occasions. This claim, however, was contested by Joondalup Health Campus operator Ramsay Healthcare and the supervising emergency department consultant doctor at the time, Dr. Yii Siow, during the coronial inquest held in May of the previous year. Despite the repeated requests, Sandipan was sent home that day. Tragically, his condition rapidly deteriorated, and his parents rushed him back to the hospital two days later, on March 24. He passed away at 10:38 pm, during resuscitation attempts, when blood tests finally identified leukemia, a diagnosis later confirmed by a post-mortem.
Dhar was compelled to leave the inquest proceedings last year during Ramsay’s testimony, accusing the hospital of misrepresenting his requests for blood tests.
Navigating Hope and Anxiety Amidst Inquest Findings
Western Australia’s health regulator and internal hospital inquiries had previously cleared the medical centre GPs and hospital staff of any wrongdoing, a conclusion that deeply angered Dhar. He expressed relief when it was announced that the coroner would investigate his son’s death in late 2024.
Dhar described the period leading up to the inquest findings as emotionally taxing for his family, yet he holds onto the hope that it will lead to positive change. “The inquest brings both hope and anxiety — hope for clarity and transparency, and for findings that are firmly grounded in evidence,” he stated.
A central focus of Deputy State Coroner Sarah Linton’s inquiry was to determine whether a blood test could have and should have been performed in the days preceding Sandipan’s death. Dhar expressed his hope that the coroner would consider mandatory blood tests in specific circumstances:
- When children present to emergency departments multiple times within a short period.
- When parents report worsening symptoms.
- When symptoms are unexplained or non-specific.
Furthermore, Dhar advocated for several key improvements within the healthcare system:
- Parental Concern as a Clinical Factor: He called for parental concerns to be recognised as a significant clinical risk factor in hospitals.
- Mandatory Documentation: He proposed mandatory recording of parental concerns during paediatric assessments.
- Clear Escalation Pathways: He stressed the need for clear protocols to escalate care when patient symptoms persist after discharge.
Dhar also seeks enhancements in the review processes for medical incidents, often referred to as SAC1 reports. He advocates for greater independence in investigations into serious incidents and improved communication channels with affected families. “Accountability and patient safety standards must be consistent across both public and private healthcare systems,” he asserted. “We hold firmly to the coroner’s commitment that Sandipan will not remain just another number within the WA health system. As his family, we cannot allow his life to be reduced to a statistic.”
A Call for Greater Oversight of Private Healthcare
Beyond immediate clinical improvements, Dhar is urging the state government to re-evaluate its contract with Ramsay Health, or at the very least, to enhance its oversight of private contractors operating public hospitals in Western Australia. He pointed to precedents in other Australian states, such as New South Wales, where governments have intervened in private hospital arrangements due to serious concerns, even transitioning facilities back into public management.
“We believe the WA government should objectively examine whether the current contractual and regulatory structure remains appropriate, and whether stronger public oversight — including potential structural reform — is necessary in the interests of patient safety,” Dhar stated.
Ramsay Healthcare chief executive Natalie Davis acknowledged the company’s commitment to learning from all incidents within its hospitals, including this one. “We await the coroner’s findings, and we will continue to implement any recommendations that are recommended by the coroner,” she said.
WA Health Minister Meredith Hammat expressed her understanding of Dhar’s concerns and her commitment to ensuring that care in WA hospitals meets community expectations. “We’re always looking at how getting the performance that we need, whether that’s hospitals that are run by the state, or whether that’s like Ramsey, where there is a public-private partnership for the provision of those services,” she commented. Hammat confirmed that the government would implement any findings presented in the coroner’s report.
