The family of Eve Brown, a First Nations woman who died at the Lightning Ridge Multi Purpose Health Service in New South Wales in July 2021, received coronial findings on Thursday which confirmed critical failures in recognising and responding to her deteriorating condition contributed to her preventable death.
Deputy State Coroner Harriet Grahame found Ms Brown, aged 42, died after presenting seriously unwell to LRMPHS and not receiving timely investigation, escalation or transfer to an appropriately resourced hospital.
At around 9am on 1 July 2021, Ms Brown presented to LRMPHS with abdominal pain and vomiting and blood gas analysis showed metabolic alkalosis. Following her initial presentation, Ms Brown's vital signs were not repeated for more than 12 hours, despite her ongoing symptoms.
Before midday, a doctor at LRMPHS examined Ms Brown and diagnosed her with a urinary tract infection. By 4pm, the doctor reviewed blood results which revealed sepsis, but Ms Brown remained at the facility overnight.
Ms Brown's condition deteriorated acutely at around 5am on 2 July 2021. By about 8am, a request was made to transfer Ms Brown to Dubbo Hospital and the flight arrived at Lightning Ridge shortly after 12.30pm, with its clinicians arriving at about 12.45pm.
Shortly before the flight arrived, Ms Brown suffered a cardiac arrest at 12.20pm and was pronounced deceased just after 1pm on 2 July 2021. She died from hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the setting of urosepsis.
The Coroner accepted that earlier recognition of the seriousness of Ms Brown's condition, urgent diagnostic imaging, consideration of differential diagnoses and timely transfer out of the limited-resources setting of LRMPHS ought to have occurred.
The Coroner also accepted that had a request for transfer been made on 1 July 2021 and achieved before Ms Brown's deterioration in the early hours of the following day, it is more probable than not that she would have survived.
Ms Brown's family said the findings bring some measure of accountability but also deep sadness.
"Eve asked for help and trusted the health system to keep her safe," the family said in a joint statement.
"Today's findings confirm that she should have been transferred and properly investigated. We hope no other family has to endure what we have."
Maurice Blackburn Associate Naomi Spigelman, who represented Ms Brown's family, said the findings were a devastating reminder of the consequences of under-resourced rural health services.
"Eve Brown's death on 2 July 2021 should never have happened," Ms Spigelman said.
"She presented to hospital critically unwell, and yet there was no discussion about the need to move her to a facility where a CT scan or other investigation could take place, until it was too late.
"This case also raises profound issues of First Nations health equity. Aboriginal people continue toexperience poorer access to timely, high-quality healthcare in rural and remote communities. We must ensure First Nations patients are able to access properly resourced hospitals, timely diagnostics and urgent retrieval when they need it - no matter where they live."
The Coroner also identified broader systemic issues affecting remote healthcare, including failures in clinical escalation, monitoring, and access to diagnostic imaging and retrieval services.
The findings included recommendations aimed at improving the recognition and management of sepsis and acute deterioration in remote health settings, to prevent similar deaths in the future.
Maurice Blackburn also represented the family in civil medical negligence proceedings against the Western NSW Local Health District.
