Preventable Death Highlights Indigenous Health Inequities in Rural NSW

A coroner has found that a 42-year-old First Nations woman, Eve Brown, likely could have survived if she had been transferred from a rural clinic to a larger hospital sooner for critical medical imaging. The inquest into her death has reignited concerns about healthcare access for Indigenous Australians in remote communities.

Details of the Case

Eve Brown, a Warrimay woman, died on July 2, 2021, at the Lightning Ridge Multi-Purpose Health Centre in northwest New South Wales after suffering a ruptured spleen. She initially presented with symptoms that were misdiagnosed as a urinary tract infection. According to the inquest, the doctor on duty should have requested a transfer to Dubbo Base Hospital for a CT scan much earlier, as her condition was serious and the cause unclear. ABC News reports that an early CT scan might have revealed the underlying condition causing the rupture.

Delayed Transfer and Cardiac Arrest

A request for a flight transfer was made, but it wasn’t arranged until 12:30 pm. Shortly before the flight arrived, Eve Brown suffered a cardiac arrest and could not be resuscitated, being pronounced dead at 1:30 pm. The NSW Coroners Court detailed that the flight arrived at Lightning Ridge shortly after 12:30 pm, with clinicians arriving at the centre around 12:45 pm.

Coroner’s Findings and Recommendations

Deputy State Coroner Harriet Grahame found that expediting the transfer the previous day would have likely saved Ms. Brown’s life. The coroner recommended that the Western NSW Local Health District review its procedures for assessing patients in small rural centres lacking comprehensive diagnostic facilities. She recommended reviewing training for nursing staff to ensure continuous and thorough patient progress notes. Mudgee Guardian reports on these recommendations.

Indigenous Health Inequities

The case has brought renewed attention to the systemic health inequities faced by Indigenous Australians. Naomi Spigelman, the family’s legal representative, stated that the case highlights the poorer access to timely, high-quality healthcare experienced by Aboriginal people in rural and remote communities. She emphasized the need for properly resourced hospitals accessible to First Nations patients, regardless of their location. AAP News covered this aspect of the inquest.

Health District Response

The Western NSW Local Health District has stated it will carefully consider the coroner’s recommendations and has offered its condolences to the Brown family. ABC News reports on this response.