A New South Wales coroner has found that the death of a 42-year-old Aboriginal woman at a remote outback hospital in 2021 was preventable, highlighting systemic failures in healthcare access for rural and Indigenous communities. Eve Brown, a Worimi woman and mother of three, died at Lightning Ridge Multi-Purpose Health Centre on July 2, 2021, while awaiting transfer to Dubbo Base Hospital for treatment of a hidden spleen injury that resulted in sepsis.
Deputy State Coroner Harriet Grahame delivered her findings on Friday, stating that expediting Ms. Brown’s transfer the previous day “would have meant [she] was in a hospital setting with intensive care and emergency surgery capabilities” and that “it is more probable than not that she would have survived.” The inquest heard Ms. Brown initially presented with unusual symptoms and was initially diagnosed with a urinary tract infection.
The coroner’s report detailed “numerous missed opportunities” in Ms. Brown’s care, including a delay in recognizing the severity of her condition and a failure to promptly arrange for a transfer to a facility equipped with CT scanning capabilities, which were unavailable at Lightning Ridge. The inquest heard evidence from medical staff about the challenges of diagnosing and treating patients in a rural setting, including difficulties in contacting doctors for assistance. Registered nurse Jamie Brizuela testified she hesitated to contact Dr. Hakeem for further guidance, fearing he “would get upset.”
Ms. Brown’s family expressed anguish over the findings. “She’s gone and she shouldn’t be, and I’m here rearing [her] three kids. She should be rearing her children, not me,” said Trina Brown, Ms. Brown’s mother, outside the court. “It’s every parent’s nightmare.” Ms. Brown’s family has been a vocal advocate for improved healthcare services in remote communities, specifically calling for a CT scanner to be installed at the Lightning Ridge facility.
However, Rachel Christmas, president of the Rural Doctors Association of NSW, indicated that installing a CT scanner at Lightning Ridge is “not viable” due to financial constraints. Dr. Christmas emphasized the need for improved training for rural medical staff to recognize serious illnesses and initiate timely referrals. “We can’t have the best of the best in every single town,” she said.
The coroner’s recommendations to the Western NSW Local Health District include using Ms. Brown’s case as a training scenario for visiting medical officers to improve their ability to identify deteriorating patients and the importance of prompt transfer decisions. A spokesperson for the health district stated they would “carefully consider the coroner’s findings and any recommendations made” and offered condolences to Ms. Brown’s family.
The inquest similarly revealed Ms. Brown was a respected local artist, with her murals adorning buildings around Lightning Ridge. Artwork created by Ms. Brown was brought into the courtroom during the proceedings by family and friends.
The Royal Flying Doctor Service was contacted on July 2, 2021, to arrange a transfer to Dubbo, but Ms. Brown suffered a cardiac arrest shortly before the aircraft arrived and could not be resuscitated. Dr. Ifran Hakeem, who initially treated Ms. Brown, told the court he was receiving counselling following her death.
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