Health services failed in care for three Doomadgee women who died of rheumatic heart disease


A coroner has found a public hospital service and a community healthcare provider failed in their care for three women who died of complications from a preventable heart condition. 

Warning: Aboriginal and Torres Strait Islander readers are advised this article contains the names and images of people who have died.

The women, known as Kaya, Betty, and Ms Sandy, lived in the Aboriginal community of Doomadgee in north-west Queensland and died from complications with rheumatic heart disease (RHD) in 2019 and 2020.

The inquest into their care was triggered after a Four Corners investigation.

In handing down her findings, Coroner Nerida Wilson was damning of the Doomadgee Hospital, managed by the North West Hospital and Health Service (NWHHS).

She found Gidgee Healing and hospitals in Mount Isa and Doomadgee failed to provide follow-up care after patients were discharged, that Doomadgee Hospital failed to follow up on reasonable concerns from Kaya’s family, and that it did not deliver culturally safe practices.

She also found the Doomadgee community lacked access to sufficient housing, showers, clean mattresses, and laundries, and that a strained relationship between the community and health services had created an environment where people did not feel safe.

“Simply put, the system has failed,” the coroner said. 

Coroner Wilson made 19 recommendations including for the health services involved and the state health department to consider adopting a risk matrix for identifying, measuring, and monitoring institutional racism within public hospitals.

She recommended a cultural leader or restorative expert be engaged to attempt to restore the trust and relationship between the Doomadgee community and healthcare providers.

Doomadgee is a remote Indigenous community in north-west Queensland.()

Minister accepts recommendations

Both Betty and Ms Sandy died at Doomadgee clinic, while Kaya was transferred to Mt Isa, Townsville, and then Brisbane hospitals where she underwent several surgeries but never recovered.

All three women had been diagnosed and lived with RHD for years in a town where rates of the illness are higher than average.

RHD has all but disappeared in non-Indigenous communities in Australia.

Betty, Kaya and Ms Sandy (from left) had severe rheumatic heart disease and died within the space of a year.()

The inquest heard an independent “guardian angel” could be appointed to provide independent oversight of how issues are managed in the community.

Queensland Health has been advised to ensure clinicians understand the purpose and function of the RHD register, and that it is explained to patients and their families.

It has also been told to identify strategies to encourage clinicians working in communities to adopt a high-risk index of suspicion for acute rheumatic fever and when treating patients in those communities.


In a statement, Queensland Health Minister Shannon Fentiman said the government would accept all the recommendations and work with the Doomadgee community to respond appropriately.

She said the findings would help improve the prevention and early intervention of RHD across the state.

The state’s chief first nations health officer, Haylene Grogan, said the women’s experiences were “a tragic reminder of the ongoing inequities that First Nations people face”.

‘Deep listening’ needed

It was recommended the NWHHS review discharge processes, consider ongoing training in cultural safety, and ensure doctors have timely access to medical records.

“They’re certainly things that we’ve already begun to do … but we’re very aware of the great amount of work that has to be done,” said NWHHS chair Cheryl Vardon.

“We’ll be acting on all of the recommendations.”

In Doomadgee, health services were provided by both the state-run hospital and by Aboriginal Community Controlled Health Service, Gidgee Healing.

Staff from both services told the inquest about difficulties in communication between the services and poor access to patient health records.

Alec Doomadgee says a lot of work needs to be done to make sure the recommendations are acted upon.()

Alec Doomadgee, a relative of two of the women, said the coroner’s remarks were vindication for Aboriginal people who had spoken out about issues in the health system.

“To hear the coroner speak the way she did … gave a lot of weight to our concerns,” he said.

“We’ve had those concerns for a long period of time: the inadequate health care, the keeping of records, just your basic everyday thing that should be afforded to Aboriginal people in the communities.”

Mr Doomadgee said there was “still a big fight ahead of us in implementing those recommendations to make sure there is actual change”.

Doomadgee is in the remote north-west of Queensland, closer to Darwin than Brisbane.()

The NWHHS is now keeping an RHD register, which files patients’ information and is shared with other health providers in the remote community.

“One of the practical changes we’ve made on the ground is that any patient presenting to Doomadgee Hospital is asked questions about symptoms and potential for rheumatic heart disease,” Ms Vardon said.

She admitted trust had been broken between the NWHHS and the community of Doomadgee.

“[It’s] got to comprise deep listening, taking on board what people are saying,” Ms Vardon said.

“[There are] grave concerns about racial profiling. That’s a very distressing thing to hear.”

The coroner also recommended consideration be given to improvements that could be made to avoid negative cultural and racial connotations being included in clinical notes.


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