Acting State Coroner Sarah Linton has concluded that the death of 21-month-old Sandipan Dhar was preventable, finding that a blood test administered two days before his passing could have detected undiagnosed leukemia and likely saved his life. The coroner's findings, detailed in an 86-page report, specifically address Sandipan's initial presentation to Joondalup Health Campus on March 22.
Linton's ruling directly contradicts arguments that Sandipan's death could not be determined as preventable. The coroner emphasized that a blood test during his first visit to the hospital could have identified the leukemia, allowing for definitive treatment and survival.
A Contested Account of Care
The circumstances surrounding Sandipan's presentation at Joondalup Health Campus on March 22, 2026, formed a central point of contention during the inquest. The coroner, Linton, noted a dispute over whether Sandipan's parents requested blood tests during this visit, ultimately preferring the account provided by Sandipan's father. This account stated that the family had requested a blood test on at least three separate occasions during that initial encounter.
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The child ultimately died two days later, succumbing to the undetected leukemia. This outcome has prompted the coroner to issue six recommendations, some of which are specifically tailored to the treatment of children within the Emergency Department at Joondalup Health Campus.
"Whether Dhar and his wife asked for blood tests at Joondalup was a point of contention during the inquest but Linton said she preferred Dhar’s evidence."
The core of the coroner's determination hinges on the belief that had the blood test been performed upon Sandipan's initial presentation, as both his parents and GP had apparently advocated for, the leukemia would have been identified, and he would have survived.
