A Perth doctor has been referred to the medical watchdog over the 'devastating' and 'preventable' death of a two-year-old boy who died following a circumcision.

A coronial inquest found Dr Raad Hassan failed in his professional duty of care when he did not take adequate steps to safeguard two-year-old David Kalunga Flynn, who died just hours after the procedure at Gosnells Medical Clinic in December 2021.

David and his eight-month-old brother, Joseph, were circumcised at the request of their mother, Alice Flynn.

Dr Hassan administered morphine to sedate David, describing it as routine, but chose not to sedate Joseph because of his age, the coroner heard.

Although David was still heavily sedated and unconscious, and Joseph was bleeding and in visible pain, both boys were discharged with their mother just after 2pm, barely an hour after the first surgery.

That evening, Ms Flynn discovered David unresponsive and cold to the touch. An ambulance was called, and both children were rushed to Armadale Hospital, where he was pronounced dead.

As Ms Flynn reeled from the tragic news about David, doctors told her that Joseph needed to be rushed to Perth Children's Hospital, where he underwent emergency surgery to stop bleeding from a damaged frenular artery sustained during his circumcision, ,evidence before the coroner revealed.

The tragic circumstances of David's death were examined during a two-day inquest in February, with the findings released this week. 

Hassan had performed roughly 6,000 circumcisions in total, about 4,000 in Iraq and 2,000 more in Australia.

Coroner Robyn Hartley ruled the cause of death as 'cardiorespiratory arrest in a young child with a likely opioid (morphine) toxicity'.

'The critical issue in David's case arose out of the administration of sedation in the form of morphine,' she said.

'Procedural sedation, particularly in children, comes with significant known risks … [which] can be mitigated if the sedationist complies with requirements aimed at ensuring patient safety.

'The three highly qualified medical practitioners who gave expert evidence at the inquest all agreed that, if David had been kept at Gosnells Medical Clinic after the procedure and monitored appropriately prior to discharge, his deterioration would have been identified and reversal of the developing opioid toxicity could have occurred.'

Coroner Hartley added: 'This would very likely have saved his life.

'Dr Hassan failed in his professional duty to take the necessary measures to ensure David's safety. His oversights were inadvertent and he has acknowledged his shortfalls and expressed deep remorse for the catastrophic consequences.'

Dr Hassan has since stopped performing circumcisions and relinquished access to morphine. He continues to practise medicine.

'With the margin for error so great, and the consequence of an intentional overdose being potentially fatal, I believe Dr Hassan made a series of poor decisions in his choice of sedating agent, mode of administration, concentration of solution and the size and type of syringe used,' Dr Hartley said.

The findings highlighted multiple failings, including not advising on fasting rules, ignoring medical guidelines, and breaching legal requirements for administering controlled drugs like morphine, all of which had 'catastrophic consequences'.

Coroner Hartley described David as a 'happy, healthy child' with no medical conditions, who 'never woke from the deep sedation administered for the circumcision.'

'David was a much-loved child taken from his family in devastating circumstances,' Coroner Hartley wrote.

'He underwent a simple, elective procedure that is generally considered to be safe when performed on healthy children.'

While the GP's professional conduct was deemed serious enough to warrant referral to Australian Health Practitioner Regulation, the coroner found it fell short of the threshold for criminal prosecution by WA Police.

Daily Mail approached Gosnells Medical Clinic for comment.

Family spokesperson Noor Blumer said they chose to speak out so that no other family would endure a similar tragedy. 

'They are a very committed Christian family and they are not the kind of people that are vindictive or out to get anybody,' she told ABC.

'I don't think there's a good outcome for them, but I think the best outcome will be if there could be an improvement in practises when making circumcisions available.

'It's really important that circumcision is something that is available to people that want to do it for whatever reasons [religious or otherwise] for their children, in safe circumstances.'