Joondalup Health Campus inquest: what patients need to know

Why this case matters for patients and families

Coronial inquests don’t often make headlines. When they do, it’s usually because what happened was serious enough that someone decided the public deserved to know.

The inquest into the death of Sandipan Dhar, a 21-month-old boy who died at Joondalup Health Campus in Perth in March 2024, is one of those cases. In findings handed down in April 2026, Acting State Coroner Sarah Linton concluded that a routine blood test, which was not performed despite a GP referral and the family’s repeated requests, would almost certainly have detected treatable leukaemia in time to save his life.

The findings don’t just tell the story of one child. They point to systemic problems at Joondalup Health Campus that may have affected other patients as well.

When Sandipan’s family asked us to represent them at the inquest into his death, we immediately recognised the importance of the case and were determined to support them. Our work included a detailed forensic analysis of the medical records, obtaining expert medical opinions, representing the family at the inquest with counsel, and drafting written submissions for the Coroner.

What the coronial inquest found

Sandipan had been unwell for more than three weeks before his family took him to Joondalup’s emergency department. His GP had referred him specifically for blood tests. His parents asked for those tests to be done. They were not.

Two days later, Sandipan was rushed back to the hospital. He died shortly after arriving. An autopsy confirmed acute lymphoblastic leukaemia, a form of blood cancer that, in children, is often highly treatable when caught early.

The coroner’s findings were clear:

• a blood test at the first emergency department visit would almost certainly have identified the leukaemia
• had treatment started at that point, Sandipan would, on the balance of probabilities, have survived
• his death involved a critical missed opportunity, not an unavoidable outcome

It’s worth being clear about what a coroner’s inquest is and isn’t. It is not a civil or criminal trial, and it does not determine legal liability. What it does do is establish an independent, evidence-based account of what happened, and the coroner’s conclusions here were stark.

Systemic failures at Joondalup Health Campus

What makes this inquest significant beyond the individual case is the coroner’s identification of institutional problems at Joondalup. The findings pointed to:

• breakdowns in clinical decision-making under high-pressure, high-volume conditions
• communication failures between staff
• gaps in how the department assesses and prioritises paediatric patients

Joondalup Health Campus is one of Western Australia’s largest and busiest emergency departments. The coroner acknowledged the pressures that creates. But pressure does not lower the standard of care patients are entitled to receive, and six formal recommendations were made to address the failures identified.

Those recommendations focused on strengthening paediatric triage and assessment processes, improving staff training on warning signs in children, and reducing the risk of similar failures in the future. The fact that six recommendations were necessary speaks for itself.

Your rights as a patient at Joondalup Health Campus and across WA

No matter how busy an emergency department may be, patients in Western Australia have clearly established rights that are legal entitlements. They include:

• the right to be properly assessed when your symptoms are persistent or worsening
• the right to have clinical requests, including GP referrals, taken seriously
• the right to raise concerns and receive a genuine response
• the right to ask questions, request further investigation, and seek a second opinion
• the right to access interpreter services or culturally appropriate support

If you feel those rights weren’t respected during a visit to Joondalup Health Campus or another WA hospital, you don’t have to accept that without question.

When does missed or delayed care become medical negligence in WA?

Medical negligence isn’t limited to dramatic surgical errors. Some of the most serious cases involve what didn’t happen: a test that wasn’t ordered, a symptom that wasn’t followed up on, a concern that was dismissed.

To establish medical negligence, a claim generally needs to show that a healthcare provider failed to meet the standard of care expected of a reasonably competent professional in that position, and that the failure caused harm. Common examples in emergency department settings include:

• failure to order clinically indicated tests
• delayed or missed diagnosis of a serious illness or condition
• inadequate assessment of a patient with persistent or worsening symptoms
• failure to act on a referring GP’s instructions or documentation
• communication failures that result in a loss of opportunity for treatment

A coroner’s finding that a death was preventable does not, on its own, establish civil negligence, as the legal test is different. But it can be highly relevant evidence, and inquest findings of this kind are often a starting point for families considering their legal options.

What to do if you’re concerned about care at Joondalup Health Campus

If something went wrong during treatment at Joondalup, or if you’ve been left with unanswered questions, there are practical steps worth taking:

• request a copy of your medical records from the hospital. You are entitled to these.
• ask the hospital directly for an explanation of the care that was provided.
• if you’re not satisfied with the response, lodge a complaint with the Health and Disability Services Complaints Office (HaDSCO).
• speak to a medical negligence lawyer to understand whether your situation warrants further investigation.

Time limits apply to medical negligence claims in Western Australia. If you have concerns, it’s worth getting advice as soon as possible.

How Maurice Blackburn can help

Our medical negligence lawyers work with patients and families across Western Australia and nationally. We understand that questioning your medical care, particularly after something has gone wrong, can feel overwhelming. It’s not a step most people take lightly.

What we offer is straightforward: an honest assessment of your situation, a clear explanation of your options, and experienced legal support if you decide to pursue a claim. Our consultations are free, confidential, and come with no obligation.

If you received care at Joondalup Health Campus and have concerns that haven’t been properly addressed, we’re here to help.

Contact us today for a free, confidential consultation.