A Noongar family is searching for answers after the death of 55-year-old grandmother Glenda Binder, whose body was found at home three days after she was discharged from a Perth hospital.
WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains images and names of people who have died.
Ms Binder, whose death is being investigated by the West Australian Coroner, called her long-term family doctor Raji Krishnan in tears from Fiona Stanley Hospital on October 13.
"She said, 'I'm not well, I'm not well,'" Dr Krishnan said.
"I said, 'If you're not well, why are they discharging you?'"
Three days later a family member found Ms Binder's body in the public housing property she had only recently moved into, having been homeless for many years.
Her granddaughter, Janita Anderson, is now seeking answers about why Ms Binder was sent away from the hospital.
"I'm just gutted," Ms Anderson said.
"For her to pass only a few days after being discharged, this is not okay.
"That does not sit right with our family."
Ms Anderson provided permission to use Ms Binder's full name and image.
The South Metropolitan Health Service said it would co-operate with the coroner's investigation and had provided information about Ms Binder's treatment to the coroner's office in November.
"We offer our sincerest condolences and sympathies to Ms Binder's family," the health service said in a statement, but declined to comment further on Ms Binder's death.
Coronial investigation
In WA, deaths are reported to the coroner if the person was "held in care" immediately before their death, or a doctor has been unable to sign a death certificate giving the cause of death, among other reasons.
According to a letter from the WA Coroner's Court to the family, a forensic pathologist concluded Ms Binder died from complications of artherosclerotic and rheumatic heart disease, including heart failure and bowel ischaemia.
But an official cause of death will not be determined until the coroner's investigation is complete, which could take a year or longer.
Dr Krishnan, who has treated Ms Binder, her daughter and granddaughters for many years, said the hospital should do an internal investigation into discharge procedures and subsequent follow-up.
She said it was out of the ordinary for Ms Binder to call her from hospital to ask for help, because she was not in regular contact.
Dr Krishnan said she told Ms Binder to ask hospital staff to call her, but she did not hear from anyone.
The hospital did prepare a "discharge summary", a document providing instructions for follow-up care.
But Dr Krishnan said records showed it was never sent to her because the hospital did not have the name of a GP on file for Ms Binder.
Dr Krishnan said it appeared Ms Binder, who was removed from her parents as a child as part of the Stolen Generations, had received appropriate treatment while in hospital.
'How do we improve?'
The case appears to illustrate what some experts believe is a gap in hospital discharge procedures for many disadvantaged people.
Dr Krishnan said she regularly saw people with difficult living situations discharged without appropriate follow-up because it was too difficult to locate them.
"Day-in and day-out I see the [vulnerable] patients and I struggle. How do we improve?" she said.
Dead within a month of missing surgery
In 2021, Noongar man Anselm Taylor died after his bed at Fiona Stanley Hospital was reallocated when he left the hospital to collect belongings at home.
He was scheduled to undergo heart surgery the following day but did not meet a deadline to get back to the hospital.
Social worker Sean Digney found Mr Taylor at home and tried to get him re-admitted but said the hospital would not take him back at that time.
Mr Digney said his interactions with the hospital worker made him feel Mr Taylor was being treated differently because of who he was.
"If he was a sort of Caucasian, white man, softly spoken, polite manners and all that, it would have been, 'Yep drop him off straight away'," he said.
"I feel like they put him the too-hard basket and it was just too difficult a task and they kind of washed their hands of him in a way."
Mr Taylor, a prominent advocate for the homeless community, died within a month of missing the surgery.
The South Metropolitan Health Service said Mr Taylor had never been refused a bed at Fiona Stanley Hospital and many efforts had been made to contact him to get him to return for treatment.
"Against medical advice and despite an Aboriginal hospital liaison officer's offer to make alternative arrangements, Mr Taylor chose to leave the hospital before undergoing surgery," the health service said in a statement.
Mr Digney said the hospital did contact him to reschedule the surgery — but not until after his death.
Professor of Rural Health at the University of Western Australia Sandra Thompson specialises in public health, policy and addressing disparities in healthcare.
She said hospital systems could be blind to the needs of more vulnerable people, who were not always able to navigate systems to advocate for themselves.
"You can actually have these little holes, and if they line up, people just fall through the gaps," Dr Thompson said.
"That's why you want to have as foolproof a system as possible.
"You want systems that look after our most vulnerable people."
She said hospital Aboriginal liaison officers did as much as they could for inpatients, but it was generally not part of their job to refer patients to additional services after discharge.
Dr Thompson said people could slip through gaps for cultural reasons, or because hospitals were generally ill-equipped to support people with drug or alcohol addictions.
She said rheumatic heart disease — suspected in Ms Binder's death — was also related to poverty and overcrowding.
'I'm frightened of dying'
The deaths of Mr Taylor and Ms Binder have made others in the Noongar community fearful of being discharged from hospital.
Ms Binder's cousin, Noelene Garlett, was distressed about being sent home from Royal Perth Hospital last Thursday, saying she still felt very unwell.
"I'm frightened of dying," Ms Garlett said. "I don't want the same thing to happen to me."
A spokesperson for Royal Perth Hospital strenuously denied Ms Garlett's version of events.
"Numerous offers of support were provided to the patient by social workers and culturally appropriate Aboriginal Health Liaison Officers," the spokesperson said.
"The patient rejected all offers of support."
The hospital said it was proud of providing high-quality care.
Ms Anderson said her grandmother's death was a tragic end to a very difficult life.
She described Ms Binder as a beautiful woman who loved to write poetry.
"She had been treated like shit her whole life," Ms Anderson said.
"She probably just thought, 'What's the point of even trying, you know?' And it's just sort of sad to think about, because she's such a beautiful woman.
"She didn't get the laughter she deserved [since she was] a baby."
