Dougie Hampson was a 36-year-old Kamilaroi/Dunghutti father of eight who died from perforated stomach ulcers after being misdiagnosed with cannabinoid hyperemesis syndrome, despite lacking key symptoms of nausea and vomiting. He was discharged after 19 hours without any scans or review by senior doctors.
The inquest found that as a result of the incorrect diagnosis, his treatment plan was inadequate and Dougie’s death was entirely preventable.
While the Coroner did not find any specific racial bias, either conscious or unconscious, played a part in Dougie’s death, she noted Aboriginality was an important factor to consider in delivering health care. The Hospital was particularly criticised for failing to consider Dougie’s indigeneity in his treatment.
Recommendations
The Coroner made key recommendations to the Health Service, including:
- the establishment of a standing First Nations consultation and advisory group in liaison with the local Aboriginal community-controlled health organisations to be consulted from time to time;
- training programs be referred to that consultation group for review and recommendation for revision and additional modules if required;
- cultural induction and recurrent training to medical and nursing staff involving face to face engagement with First Nations people from the community and catchment area, and ensuring training includes information specific the Aboriginal and Torres Strait Islander community;
- when documenting a plan of management, consideration is given to what outstanding investigations are to occur, whether there is need for medical review, who is required to take the review and whether it should be conducted during the patient’s stay.
It was also recommended that NSW Health should consider amending the Aboriginal and Torres Strait Islander – Recording of Information of Patients and Clients policy to ensure all medical and nursing clinicians are advised of the Aboriginal or Torres Strait Islander status of a patient to ensure that it is considered in their treatment.
The treating emergency department doctor was also referred to the Health Care Complaints Commission for investigation into whether he engaged in unsatisfactory professional conduct in his treatment and misdiagnosis of Dougie.
Takeaways
This inquest provides insight into the need for improved cultural safety and understanding of the culture of First Nations persons. It also highlighted the realities of the cultural barriers and poorer health outcomes that statistically befall First Nations people.
As illustrated by this matter, there are opportunities for the public health system to review their training programs and policies to establish a culturally safe health system which is committed to improving Indigenous health, social and emotional outcomes.
By “engaging in a culturally respectful way, connecting, building rapport, being mindful of the barriers and historically poor outcomes and factoring that into the medical process” both individual health practitioners and providers can deliver a more supportive healthcare system.
The inquest echoes the findings of the Cultural Safety in Health Care for Indigenous Australians – monitoring framework, that all structures, policies and processes across the health system play a role in delivering culturally respectful health care, and cultural safety cannot be improved in isolation from the provision of health care.
A copy of the Coroner’s finding can be found here.
Written by Gemma McGrath and Tom Gillard
