Joondalup Health Campus: External review recommends children’s ED overhaul, but no blame for Sandipan’s death

An independent review ordered in the wake of toddler Sandipan Dhar’s death at Joondalup Health Campus recommended an overhaul of its paediatric emergency department — but cleared the hospital of wrongdoing. The death of 21-month-old Sandipan in March came after two presentations at the ED in which his desperate parents begged for the blood test which could have diagnosed his leukaemia, and potentially saved his life. The review also examined the case of 10-year-old Olivia Bakranich-Fowler, who did not receive vital anti-venom for a deadly tiger snake bite until 17 hours after she was bitten in May. The families of both children said their concerns were repeatedly ignored by staff at Joondalup. An initial report done by hospital operator, Ramsay Health Care, assessed Sandipan’s case as a SAC1 event — which is a potentially avoidable death attributable to “health care provision (or lack thereof)“. The findings of the independent report released on Tuesday were “consistent with the initial root cause analysis (SAC 1) of these cases”. That investigation into Sandipan’s case cleared doctors and nurses on duty on his first visit and on the night of his death of any wrongdoing. The 33-page independent report released on Tuesday was prepared by Queensland emergency physicians Dr Shahina Braganza and Dr Christa Bell. It recommended “expanding the space, resources, supervision, education, and governance within JHC paediatric emergency services”. That would include “adjustments to staffing levels and skill-mix”, according to the number of children presenting to the ED and how severe their illnesses were. The initial Ramsay report found “no gaps in numbers or senior skill mix” of staff during both of Sandipan’s visits to ED. A major recommendation from the independent review noted that the paediatric ED “requires enhanced functioning (structure, process, and resource related) as a priority”. Several other recommendations focused on the need for “enhanced” or “augmented” functioning of the ED, including further education and training in caring for children with a “focus on ‘non-technical skill’ e.g. listening to patients/parents, communication”. Ramsay Health Care State manager for WA Shane Kelly welcomed the findings, saying the review was “designed to help restore the confidence of the community in the hospital”. Dr Kelly also said the hospital had revised its process for treating snake bites after Olivia’s diagnosis was missed. He said staff involved in the incident had received further education and training. “While the 33-page report highlights opportunities for further improvement, we feel reassured knowing the independent review findings are consistent with our own root cause analysis (SAC1) investigations into both cases,” Dr Kelly said. He confirmed an “ED redesign task force” has been created to oversee the implementation of the recommendations. The panel also said a “dominant theme” of the review was around parental concern, identifying that “improvements can be made with respect to how parents express and escalate concern, and how clinicians can respond to these concerns”. A 2021 inquiry into Perth Children’s Hospital following the death of Aishwarya Aswath highlighting “the importance of the parent’s extraordinary role” in recognising deterioration in their child. It also recommended that the role be “reinforced and embedded” through all medical policy and training State-wide. And the SAC1 report into Sandipan’s death recommended JHC review its information and education resources available in the paediatric ED. Dr Kelly said it continued to be a recommendation because “education and learning is a continuous process”, but he could not say how staff would be educated differently as a result of subsequent recommendations. “I think it’s important that we continue to educate people. It’s not something that you can do once and it stays,” Dr Kelly said. “We need to put our minds to exactly what programs we’re going to need to run to make that work well.” A coronial inquest should also be considered, the report summary said, because it would have scope to “explore the GP phase of care” as well as provide Sandipan’s family with closure, “particularly over remaining points of conjecture in his care”.