Independent review of Joondalup Health Campus found responses to parent concerns were inadequate

A Perth hospital has vowed to improve its pediatric emergency service following an investigation into the death of a toddler and the misdiagnosis of a girl who was bitten by a deadly snake.

An independent review of two cases found that communication with parents was inadequate and they described feeling “disempowered” when making decisions about their child’s diagnosis and care.

In March, baby Sandipan Dhar, from Perth, died at the Joondalup Health Campus after being sent home without a blood test two days earlier.

Sandipan was admitted to the hospital’s emergency department on March 22 after suffering from a persistent fever for several weeks, but was sent home after being assessed.

His parents said they clearly asked for blood tests but were denied.

Two days later, Sandipan’s condition worsened further and the family brought him back to the emergency room.

He died there later that evening, and an autopsy revealed that he had acute lymphoblastic leukemia (ALL).

An independent review released Tuesday found Sandipan’s clinical care was acceptable and it was reasonable that medical staff did not order blood tests during the baby’s first appearance.

But Sandipan’s family remains dissatisfied with the approach to healthcare and the decision-making of doctors.

Call to Responsibility

They would like to see a full and thorough investigation into the actions of individual doctors involved in Sandipan’s treatment and a review of the public-private partnership contract between the WA Government and Ramsay Health Care, operator of the Joondalup medical campus.

Sandipan’s father Sanjoy Dhar was not satisfied with the report’s findings but welcomed the recommendation for a coroner’s inquest.

He hoped the coronial inquest would look into the actions of all the doctors involved in his son’s treatment, including the GPs he visited several times before he was admitted to hospital.

“If Sandipan had been diagnosed and treated properly, he should have been with us today,” Mr Dhar said.

“Justice delayed does not mean justice has been served.

Health Minister Amber-Jade Sanderson welcomed the report’s findings.

“What’s very important is the importance of listening to parents,” she said.

“Sandipan was not old enough to describe his symptoms himself, but he didn’t have to because his parents were with him.

“I believe the Dhar family when they say they are strongly protective of their child.”

Snakebite bug

In May, a 10-year-old girl named Olivia was admitted to the Joondalup Health Campus with a suspected snake bite.

Judging by Olivia’s symptoms, her mother was sure she had been bitten by a tiger snake.

But after conducting a blood test, hospital staff mistakenly concluded she did not have cellulite and advised her to go home and take antihistamines.

But Olivia’s mother disagreed with the diagnosis and instead took her daughter to Perth Children’s Hospital, where staff reviewed the same blood results and concluded she had indeed been bitten by a tiger snake.

By the time she was treated, 17 hours had passed since the snake bite and she was lucky to be alive.

Olivia spent three days in the hospital recovering.

“There is an unqualified admission of a series of errors that led to (Olivia’s) mother leaving the emergency room and taking her directly to another hospital so she could be properly diagnosed and treated,” the report said.

Investigators discovered that Olivia was experiencing ongoing side effects from her ordeal.

“After the incident, (Olivia) initially felt like a superhero for surviving the snake bite and was respected by her social circle,” the report states.

“However, she had bouts of health anxiety and regularly asked her mother to monitor her sleep to make sure she was still breathing.”

Both Olivia and her mother expressed frustration and disillusionment with the Joondalup Health Campus and said this was compounded by the fact that they only received a response to their complaint after taking their story to the media.

Nine recommendations

The report found that in both cases, a clear theme was inadequate recognition and response to parental concerns.

It made nine recommendations related to improving communication with parents, documentation, discharge and processes, staffing, nursing training and communication between hospitals and GPs.

Ramsay Health Care state manager Shane Kelly said the hospital would take action to quickly implement the recommendations.

“We have made a number of improvements that were highlighted in the independent report, including the introduction of a new snakebite assessment tool and scheme,” Dr Kelly said.

“We’ve updated our e-discharge to include additional tips on parent communication and concerns, return-to-hospital guidelines and more.”

The report recommends further research into the care provided by GPs.

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