A coroner’s investigation into the deaths of three Indigenous women with rheumatic heart disease has uncovered failures in the health systems of a remote Queensland community. The deaths of Yvette Booth, Adele Sandy, and Shakaya George within a span of 18 months prompted an inquest into these otherwise natural cause deaths. Coroner Nerida Wilson presented her findings on June 30 in Cairns, highlighting the shortcomings in the healthcare provided to these women.
Yvette Booth, also known as Betty, passed away in September 2019 at the age of 18, while Adele Sandy, referred to as Ms Sandy, died at the age of 37 in May 2020. Both deaths occurred at the Doomadgee Base Hospital. Shakaya George, known as Kaya, died in September 2020 at the Queensland Children’s Hospital Brisbane when she was just 17. All three women suffered from rheumatic heart disease (RHD), a condition that can be prevented and is most commonly found in impoverished communities.
According to Wilson, Indigenous Queenslanders are 582 times more likely to acquire RHD compared to their non-Indigenous counterparts in the same state. This alarming figure underscores the urgent need for improved healthcare services for Indigenous communities.
The inquest was one of several investigations conducted into the deaths of these three women, all of which revealed significant deficiencies in record keeping and information sharing within the healthcare system. Wilson emphasized that the aim of these inquiries should not be to assign blame to individuals but to recognize the systemic failures that led to these tragic outcomes.
The coroner asserted, “Simply put: Systems failed.” These failures impacted not only the three women but also the healthcare professionals working in Doomadgee. A lack of information sharing and record keeping deprived these professionals of the necessary support and resources required to provide adequate healthcare services.
To address these shortcomings, Wilson put forward 19 recommendations. These included the engagement of an expert to collaborate with the community and hospital services in defining roles, identifying gaps, and streamlining the management of RHD patients. Additionally, Wilson called for a restorative expert to repair the strained relationship between clinicians and health services and a cultural leader to rebuild trust and rapport between the community and healthcare providers in Doomadgee.
The coroner’s findings also highlighted the inadequate living conditions faced by the people of Doomadgee. Insufficient access to washing machines, beds, and quality produce was identified as an issue. Local elder Mr. Barry Walden shared during the inquest that many individuals in the community were limited to the resources available locally due to a lack of personal vehicles or the financial means to travel to nearby major centers for essential purchases.
In light of this, Wilson recommended that the government, in consultation with the community, consider establishing a laundromat and showers or seek assistance from an organization to provide these facilities. These provisions would contribute to improved living conditions for the community.
Other contributing factors to these deaths, as identified by Wilson, included a lack of basic health education and awareness, the absence of a formalized RHD screening program, tensions between health services, mistrust of the government, and fly-in fly-out models of service delivery. All of these factors compounded the challenges faced in Doomadgee and further emphasized the need for comprehensive healthcare reform.
The coroner emphasized the need to address racism at an institutional level and recommended that any form of racism be identified, measured, and monitored. Wilson specifically suggested that Queensland Health, the Northwest Hospital and Health Service, and Gidgee Healing, which provides primary health services, improve their clinical notes to avoid implicit negative cultural and racial connotations.
In concluding her findings, Wilson emphasized that healing is the starting point for Doomadgee. Repairing relationships at all levels would require significant time and care. State Health Minister Shannon Fentiman welcomed the coroner’s recommendations and committed to working with the Doomadgee community to address the issues identified. Fentiman acknowledged the importance of improving the prevention, early intervention, and management of RHD.
Chief First Nations health officer Haylene Grogan expressed her condolences for the tragic deaths and stressed that they serve as a reminder of the ongoing inequities faced by First Nations people. The deaths of Yvette Booth, Adele Sandy, and Shakaya George underscore the urgent need for systemic changes and improved healthcare outcomes for Indigenous communities.
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