Rural doctor missed vital call in Indigenous death
The family of a woman who died at an ill-equipped rural clinic say her death is an example of the health inequalities still experienced by Indigenous Australians.
Warrimay woman Eve Brown died of shock on July 2, 2021, following an undiagnosed ruptured spleen at Lightning Ridge Multi-Purpose Center in northwestern NSW.
The inquest into his death found he was likely to have survived had the centre’s doctor requested he be transferred to Dubbo Base Hospital, 350km away, for CT imaging, which was not available at Lightning Ridge.
The coroner found that Ms Brown had unusual symptoms and was initially diagnosed with an acute urinary tract infection, but the uncertainty about her condition should have caused further concern.
The 42-year-old patient applied to the center at 9.30 in the morning the day before he died, but his condition worsened in the early morning hours of July 2.
A request was made for a flight transfer but could not be arranged until 12.30pm.
Ms Brown suffered a heart attack just before the plane arrived and was pronounced dead at 1.30pm.
Deputy state coroner Harriet Grahame found the doctor should have referred Ms Brown for CT imaging in Dubbo long before her condition worsened.
Multiple medical experts told the inquest that Ms Brown’s symptoms were sufficiently serious that their cause was unclear enough to warrant a decision to transfer on 1 July.
Ms Grahame said an early CT scan may have revealed the underlying condition causing the tear.
Ms Grahame wrote in her findings: “Early transfer… would also have meant that she (Ms Brown) would have been in a hospital setting with intensive care and emergency surgery facilities should her spleen rupture.”
Ms Grahame suggested the Western NSW Local Health District review its procedures for assessing patients in smaller rural centers with fewer diagnostic facilities.
The district should also review the training of nursing staff to ensure patient progress notes are recorded on an ongoing basis, not just at the end of a shift.
Ms Brown’s family’s legal representative at the inquiry said her case revealed deep issues around Indigenous health inequality.
“Aboriginal people continue to experience less access to timely, high-quality healthcare in rural and remote communities,” said Naomi Spigelman.
“We must ensure that First Nations patients, no matter where they live, have access to appropriately resourced hospitals when they need them.”
In a statement, the health district said it would carefully consider the coroner’s recommendations and offered its sincere condolences to Ms. Brown’s family.
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