A Queensland coroner has ruled institutional racism and a lack of cultural competency from health services contributed to the deaths of three Aboriginal women in the remote Indigenous community of Doomadgee, in northwest Queensland.
On Friday in Cairns, coroner Nerida Wilson said the deaths of Doomadgee residents Adele Sandy in 2019, aged 18, Yvette Booth in 2020, aged 17, and Shakaya George in 2020, aged 27, were caused by complications due to rheumatic heart disease (RHD), and with proper and adequate care could have been avoided.
In her 137-page report, Wilson identified a lack of collaboration between health services in Doomadgee, a failure to provide adequate care and a lack of “cultural competency” had led to a “complete and fundamental breakdown of trust” between the community and the health providers servicing them.
The coroner’s report identified a lack of communication between multiple agencies servicing the community had caused a fragmentation of vital health information which threatened the “data sovereignty” of patients.
Other factors which contributed to the women’s deaths included:
No formalised RHD screening program
Faults with the “Band-Aid solutions” of fly-in-fly-out models of services
Challenges retaining staff who are adequately trained in cultural competency
Overworked staff who at times work 24-hour shifts
A need to better inform the community of the dangers of RHD
Non-identification and treatment of skin sores and sore throats
A lack of access to nutritional food
A lack of access to health hardware such as laundry facilities
Overcrowding and a lack of adequate housing
A general mistrust of government in the community.
Wilson concluded that health services needed “resetting”.
“Without exception, all involved, individuals and organisations, have acknowledged the circumstances of the deaths and identified the gaps … All say they want to do better.”
Responding to the findings, Queensland’s chief First Nations health officer, Haylene Grogan, said in a statement: “The passings of Betty, Ms Sandy and Kaya are a tragic reminder of the ongoing inequities that First Nations people face.
“It is with deep sadness that I acknowledge the sorry business experienced by their loved ones and the extended period of sadness in Doomadgee for their recent losses.”
The state health minister, Shannon Fentiman, said the government accepted all 19 of the coroner’s recommendations and “will work with the Doomadgee community, including elders and local health providers, to respond appropriately.”
“Health system leadership and providers have a clear role resetting health services and healthcare delivery while ceasing to be complicit in the injustices and inequities in healthcare systems,” Wilson said.
The Coroner identified that institutional racism in Queensland Health has been a long and ongoing issue.
A report commissioned by the Queensland Human Rights Commission and the Queensland Aboriginal and Islander Health Council (QAIHC) in 2017 identified extreme levels of racism in many Queensland Health centres across the state.
A QHRC spokesperson said a planned follow-up review of the study did not take place due to the impact of Covid.
Earlier this month a report by the Queensland auditor general said “Queensland Health must improve how it delivers culturally appropriate care”.
It recommended the state implement a coordinated strategy to reduce the number of First Nations people from remote and rural areas failing to attend specialist outpatient appointments.
It also called for a systematic way of measuring how effectively Queensland Health delivers culturally appropriate care.
In her closing remarks on Friday, Wilson said: “At an institutional level, it is essential that racism in all its forms, reasons, oral and by action can be identified, measured and monitored.”
