The Queensland Health Ombudsman has released a scathing report into the preventable death of a First Nations woman at Doomadgee Rural Hospital in the state's north-west, describing poor record-keeping, "completely unacceptable" follow-up in care and racial stereotyping.
WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains images of a person who has died, used with the permission of their family.
Adele Sandy, 37, a mother of four children who had been diagnosed with life-threatening rheumatic heart disease since she was a child, died at the remote hospital after previous presentations to the emergency department, only to be sent home with Panadol.
The Queensland Health Ombudsman's report followed a Four Corners investigation last year, Heart Failure, into the deaths of not just Ms Sandy, but also her teenage niece, Shakaya George and Shakaya's best friend, Betty Booth, who also had rheumatic heart disease and had been turned away with Panadol from Doomadgee Hospital.
Two months before Ms Sandy died, in March 2020, Queensland Health completed a review, Betty's Story, into the failures of care for Betty Booth before she died, finding clinical risk and poor governance.
The Ombudsman's report into Ms Sandy's death said it was "concerned with the lack of progress" since Betty's Story was delivered.
"The tragic loss of Miss Sandy is an ongoing source of grief for the Doomadgee community which is deepened with the knowledge that many of the issues identified in the 'Betty's Story' report are replicated in Miss Sandy's care," the report said.
"It is evident that clear and committed action is required to address the issues identified in this report to avoid further preventable deaths."
The Queensland Health Ombudsman's report found that clinical advice noted "that Doomadgee Rural Hospital's records in the two years preceding Miss Sandy's passing were not to the required standard with obvious deficiencies in clinical note keeping".
One investigating doctor providing a clinical review for the Ombudsman "opined that the Doomadgee Rural Hospital clinical records for Miss Sandy in the two years prior to her passing [were] 'completely inadequate'".
"…Concerningly, the sparsity of clinical notation and incomplete documentation was noted to have impacted on both expert clinical advisors' ability to answer questions in relation to Miss Sandy's care," the report said.
The investigating doctor found "the documented hospital follow-up of Miss Sandy [in relation to management of her rheumatic heart disease] was completely completely unacceptable, ad hoc and with no clear plan for triggering a recall system and how this recall was undertaken".
'We need to be treated like humans'
Ms Sandy's husband, Edgar Sandy, said when he read the report it took him right back to the night that she died.
"I was relieved, but I had a bit of tears, too, to see that [the Queensland Health Ombudsman] was with us, instead of with the hospital," Mr Sandy said.
"It's been a long road down that path for us, it was depressing and sad – I'm glad they've listened to us, but there's still much to do.
"Hopefully [this report] will help not just this community, but other communities too.
"A lot of doctors and nurses need to see that we're human too – we need to be treated like humans."
Ms Sandy's family told Four Corners for Heart Failure and the Ombudsman that she never drank alcohol, but the Ombudsman's report said the clinical notes showed "regular questioning regarding alcohol use when there were reportedly no alcohol problems [which] shows some potential racial stereotyping".
The investigating doctors also criticised the hospital's failure to make family members welcome in the hospital when a patient is critically ill.
"Whether the family were not allowed in the clinic, or 'felt' they were not welcome in the clinic are both cultural safety issues," the report said.
While Ms Sandy was dying in Doomadgee Hospital, her mother Eunice Diamond said she and her two sisters were not allowed to go into the hospital to comfort her daughter, and were locked outside in the baking heat while Ms Sandy fought for her life.
"I felt like a animal, mate, hanging around the door, for my daughter," Ms Diamond told Four Corners.
"I was like the horse that come hanging round the door for my foal. And they wouldn't let me in there."
Ms Diamond was angry and hurt that it was police, not hospital staff, who communicated to her that her daughter had died.
Victim's families feel 'vindicated'
The report said Doomadgee Regional Hospital denied they contacted the police, but that "the use of police to communicate updates regarding medical treatment to relatives is both unethical and poor socio-cultural practice in most aboriginal communities".
"In particular, the presence of police compounded mistrust in the context of the specific local history involving the Doomadgee community and Doomadgee Regional Hospital," the investigating doctor said.
Ms Sandy's cousin, Alec Doomadgee, fought alongside her husband to have her case investigated and said they had been "trying to ask for a better health system so that this never happens again, that's all we're asking for".
"We certainly feel vindicated by the Queensland Health Ombudsman's findings and we are looking forward to the report of the Queensland Coroner too," Mr Doomadgee said, referring to the findings of a Coronial inquest into the three women's deaths expected in coming weeks.
"To finally be heard by a system where we felt that our concerns had fallen on deaf ears makes us feel hope for future generations – for the next Adele Sandy, Betty Booth and Shakaya George," he said.
"It's good to finally be heard."
In a statement, North West Hospital and Health Service acting chief executive Sean Birgan offered condolences to all families who have lost loved ones to rheumatic heart disease.
He said the health service, which runs Doomadgee Rural Hospital, valued the Ombudsman's report and said actions had been taken in relation to most recommendations, with some already implemented in full.
"We are committed to improving the prevention, early intervention and management of rheumatic heart disease and will work with the Doomadgee community, including elders… and local health providers, to achieve this locally," Mr Birgan said.
"We acknowledge that while the review focused on system issues in Doomadgee, the recommendations apply across all First Nations communities and the learnings will be shared across all Hospital and Health Services in Queensland," he said.
