A Father’s Quest for Accountability: Sandipan Dhar’s Tragic Case Spurs Calls for Systemic Health Reform in Western Australia
The devastating loss of 21-month-old Sandipan Dhar in 2024 sent shockwaves through Western Australia’s health sector. Now, his family’s tireless advocacy is poised to bring about significant changes, with the long-awaited findings of a coronial inquest into his death on the horizon. Sandipan’s father, Sanjoy Dhar, has bravely channelled his profound grief into a determined pursuit of a more robust and accountable healthcare system, ensuring his son’s memory becomes a catalyst for positive reform.
“We will continue to pursue every lawful avenue available within the Australian system,” Mr. Dhar stated, his resolve evident as he anticipated the coroner’s report. “This is not about politics. It is about transparency, accountability and systemic reform. Australia is a democracy, and public institutions are ultimately accountable to the community.”
Mr. Dhar has engaged with key figures across the political spectrum, including the state health minister, the opposition leader, shadow health minister, and Greens spokespersons. He reports receiving assurances of support for meaningful reform from across party lines. “I remain cautiously hopeful,” he shared. “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 Critical Days Leading Up to Sandipan’s Death
Sandipan passed away on March 24, 2024, at Ramsay Health Care’s Joondalup Health Campus, succumbing to complications arising from undiagnosed acute blastoma leukemia. This form of leukemia, while common, is typically curable, yet Sandipan’s illness went unrecognised for over a month after he began experiencing persistent, mild fevers.
The timeline of events leading to his death highlights a series of concerning interactions with the healthcare system. On February 15, Sandipan’s mother, Saraswati, took him to Key Largo Medical Centre after he sustained a leg injury from jumping off a bed. He was assessed and deemed to be fine. He returned on February 19 for his scheduled immunisations.
Approximately a week later, Sandipan’s parents sought medical attention again due to recurring fevers. On March 20, they returned to Key Largo, where a general practitioner prescribed paracetamol and antibiotics. The doctor noted a slightly elevated temperature, pus on Sandipan’s tonsils, and a mildly inflamed right ear.
Two days later, with symptoms persisting and his temperature reaching 38.3 degrees Celsius, Sandipan’s parents brought him back to Key Largo. They requested a blood test, but were instead referred to Joondalup Health Campus with a GP’s letter recommending urine and blood tests.
It was during this visit to Joondalup Health Campus that Mr. Dhar claims his family explicitly requested a blood test on at least three occasions. However, this assertion 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 family’s requests, Sandipan was discharged 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. Blood test results obtained during these efforts subsequently identified leukemia, which was later confirmed by a post-mortem examination. Mr. Dhar was compelled to leave the inquest proceedings during Ramsay’s evidence, expressing his accusation that the hospital had misrepresented his requests for blood tests.
Navigating Hope and Anxiety: The Inquest’s Significance
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 has deeply angered Mr. Dhar. He expressed a sense of relief when he learned that the coroner would be investigating his son’s death in late 2024.
Mr. Dhar acknowledged that the anticipation of the inquest findings has been an emotionally taxing period for his family. However, he remains hopeful that the process will lead to substantive changes. “The inquest brings both hope and anxiety — hope for clarity and transparency, and for findings that are firmly grounded in evidence,” he stated.
At the core of Deputy State Coroner Sarah Linton’s inquiry is the crucial question of whether a blood test could have and should have been performed in the days preceding Sandipan’s death. Mr. Dhar has put forth several recommendations for the coroner’s consideration, advocating for:
- Mandatory Blood Tests: He proposes that mandatory blood tests should be implemented when children present to Emergency Departments multiple times within a short period, when parents report worsening symptoms, or when symptoms are unexplained or non-specific.
- Parental Concern as a Clinical Risk Factor: Mr. Dhar calls for parental concerns to be recognised as a valid clinical risk factor in hospital settings, with mandatory documentation of parental concerns during paediatric assessments.
- Clear Escalation Pathways: He stresses the need for clear escalation pathways to be established for cases where symptoms persist after a patient has been discharged.
Furthermore, Mr. Dhar seeks improvements in the review processes for medical incidents, such as the SAC1 reports related to his son’s case. He advocates for enhanced 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.”
Re-evaluating Private Healthcare Contracts
Mr. Dhar also urges the state government to conduct a thorough review of its contract with Ramsay Health, or at the very least, to bolster its oversight of private contractors managing public hospitals in Western Australia. He pointed to precedents in other Australian jurisdictions, citing New South Wales where governments have intervened in private hospital arrangements due to serious concerns, leading to facilities being transitioned back to 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.”
Ramsay Healthcare chief executive, Natalie Davis, acknowledged the company’s commitment to learning from incidents within its hospitals. “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 Mr. Dhar’s concerns and reiterated the government’s commitment to ensuring that care at 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 stated. The Minister confirmed that the government would implement any findings presented in the coroner’s report.
