Noongar woman Michelle Nelson-Cox cannot reconcile the disparity between the respect her son commanded in life and the way he was treated by hospital staff in the moments before his death.
Warning: Aboriginal and Torres Strait Islander readers are advised that this article contains images and names of a person who has died.
Ms Nelson-Cox's son died of a heart attack in 2019 at Joondalup Health Campus, which has since apologised to the family for breaching its duty of care leading to his death. He was 36.
Ms Nelson-Cox said her son, Barry Nelson, was a gifted and gentle man, a wonderful father, and a highly regarded colleague at his job as a loader operator on the Mitchell Freeway expansion.
But she said that was not how he was treated at the Joondalup hospital, where she tried repeatedly to warn staff he was having a heart attack.
"I explained to them about the family history and the fact that I'd been through it with my second son on two occasions where he had two heart attacks," Ms Nelson-Cox said.
"I begged them to do an ECG, just to rule out the probability that he isn't having a heart attack.
"[The staff] were quite aggressive and disrespectful in their body language, ignoring my concerns."
The hospital has admitted to failing to provide a timely diagnosis of his heart attack and failing to recognise the increased risk factors for Mr Nelson as a member of the Indigenous community.
Mother recalls pleas for an ECG
In an emotional interview with ABC Radio Perth host Nadia Mitsopoulos, Ms Nelson-Cox recalled the pain of watching her son having a heart attack and being powerless to intervene.
She said hospital staff believed he was having an allergic reaction to a recent cortisone injection, and initially treated him for that rather than the heart attack he was experiencing.
Ms Nelson-Cox, who is a former chairperson of the WA Aboriginal Health Council, said it was only after Mr Nelson collapsed that staff at the hospital decided to do an ECG to test his heart.
A decision was made to send Mr Nelson to Sir Charles Gairdner Hospital for further treatment, she said.
"And as they wheeled him out he grabbed my hand and he looked at me and he said, 'Mum, I'm not gonna die am I?', and I said, 'No son, you're not gonna die, you're gonna be OK'."
She said she drove to the second hospital in a state of shock.
She said specialists at Sir Charles Gairdner operated on Mr Nelson but ultimately returned with devastating news.
"I was expecting them to say, you can go in [to see him] fairly soon," Ms Nelson-Cox said.
"Instead, I get the most horrific words that a mother could ever hear, that will haunt me for the rest of my life, and they say to me, 'I'm very, very sorry, but we couldn't save your son'."
In the three years since her son's death, Ms Nelson-Cox has fought for changes within the hospital system.
She successfully negotiated eight recommendations that the Joondalup Health Campus agreed to implement.
They included the development of a training plan to increase staff awareness of risk factors for members of the Indigenous community.
"Hopefully, you know, if somebody can learn from my pain … I can help them," she said.
"Because it's been a silent battle that I've had to carry for so many years without going to the media, or going to petition."
Hospital reiterates apology
Joondalup Health Campus said in a statement that it reiterated its apology to Mr Nelson's family, and acknowledged the grief and anguish caused by his loss.
"The hospital has met with Mr Nelson's family several times, and has been open and transparent with the findings from the various reviews into his care," the statement said.
"Given legal discussions with Mr Nelson's family are ongoing, the hospital is unable to make further comment at this time."
Slater and Gordon senior associate Briee Rogers, who has been representing Mr Nelson's family, said the family was yet to make submissions on how much compensation it should receive.
Ms Rogers praised Ms Nelson-Cox for her advocacy and commended the hospital for its response to Mr Nelson's death.
"It's been an excellent step from the hospital to be prepared to speak to us on an informal basis and put aside some of the issues that we would normally have to prove, and that would drag out the process," she said.
