Naomi Williams, 27, died when she was six months pregnant from meningococcal and septicemia, hours after being sent home from the emergency department of Tumut regional hospital. Photograph: courtesy of the Williams family
Gurrumuls allegations have been rejected by the Northern Territory government out of hand without any meaningful inquiry, the report prepared for the Human Rights Commission by Newhouse and his team states.
Howevere, Dr Dinesh Arya, executive director of medical services at Royal Darwin Hospital, said the idea that Gurrumul had been racially profiled was ridiculous.
It is nonsensical to even consider that very hardworking health professionals would consider racially profiling anyone or making clinical decisions that are not based on clinical need, he said.
At every point in Mr Yunupingus assessment, he was clinically assessed, and a decision was made about what clinical care he should receive and the care he received was according to plan.
The report prepared for the Human Rights Commission by Newhouse and his team says: There are many cases like Jane and Gurrumul. There are also many other challenges that Indigenous Australians have to confront during and after hospital visits that deserve attention.
Naomi Williams, 27, did not survive her visit to the emergency department of Tumut hospital, in regional New South Wales, on New Years Day this year. Her case is another being examined by the project.
A coroner found that Williams, a Wiradjuri woman, died of meningococcal and septicaemia, a dangerous blood infection that can attack and affect organs including the heart. She died hours after being sent home from the emergency department of Tumut hospital with paracetamol. She was six months pregnant.
She was told to take some Panadol and sent home, her mother, Sharon Williams, wrote in a letter to the states health minister, Jillian Skinner. Within 24 hours she was dead. How could this happen?
Like Jane, Naomi had also attended the emergency department on previous occasions in the weeks before her death.
On one of those visits, Naomi was referred by hospital staff to drug, alcohol and mental health services. But Williams said that her daughter did not drink or use drugs apart from occasionally using marijuana.
A spokeswoman for the Murrumbidgee local health district, which oversees Tumut hospital, said that meningococcal meningitis could be very difficult to diagnose in the early stages of the disease as many symptoms are common to many mild viral illnesses.
All hospital procedures had been followed, the spokeswoman also said, adding that the hospital now used a critical care advisory service, which included the use of telehealth cameras to link to specialist clinical advice at Wagga Wagga rural referral hospital.
Naomis is a story that resonates with Samuel and Norma Dinah, who live in Western Australia. Their 44-year-old son, Samuel Jr, died in April 2013 from an ear infection that spread to his brain. In the month before his death, an ambulance had been called three times, his father said.
And, three times, they sent him home with Panadol, he said.
Samuel Sr cries as he remembers his sons final visit to the hospital.
They picked him up from my daughters house in the ambulance and they gave him a morphine shot because the pain was too strong in his head, Dinah says.
And that was the last of him. He had a massive ear infection and his eardrum burst, and the infection spread to his head.
Norma said Samuel was braindead by the time he arrived at Sir Charles Gairdner hospital. The Dinahs were told they should allow doctors to turn off his life support.
If they had of done a brain scan or something like that all those times he went to hospital before they might have found something, Samuel said. We miss him to bits.
The Dinahs say they have not received a report from the WA coroner.
The WA health minister, John Day, told Guardian Australia that he understood Jane and the Dinah families concerns and said he had asked for a briefing on those cases.
Health services in Western Australia are committed to treating all patients with compassion, respect and care, whatever their racial or ethnic background, Day said.
Health staff in WA are required to undertake mandatory training using an electronic learning package, Aboriginal Cultural eLearning a healthier future. Since its introduction on 1 July 2015, in excess of 28,000 WA health staff have completed the training.
He could not comment further for privacy reasons, he said.
An expert in rural and Indigenous health, Prof Sandra Thompson, said in rural and regional hospitals in particular: You have got people who are not the most on top of their game treating people with complex health problems.
Thats a bit of a problem … I think we have to say the health system doesnt work perfectly and there are errors that get made. But we have to learn from those errors. Sometimes, it is too easy for things to be brushed under the carpet.
Thompson said she was familiar with Janes case and that there have been some real insults in the way its been managed.
Id like to do a review of how Aboriginal people who come to emergency departments with pain are being treated, as I think we could learn quite a bit about that, she said.
I certainly think there needs to be a review of some of the deaths that have occurred from those who presented to an emergency department a short time before they died. But there are barriers to getting through the incredibly onerous systems and gatekeeping that exists in the health industry.
Thompson was among the experts to give evidence at the inquest of an Indigenous woman identified only as Ms Dhu, who died in 2014 at Hedland Health Campus in WA from septicaemia and pneumonia. Ms Dhu, 22, had been given painkillers as the only treatment at an emergency department hours before she died.
The coroner heard that a police officer was caught by a security camera saying Ms Dhus condition was a good deterrent not to take drugs. Negligible amounts of methamphetamine and marijuana were found in her blood but a coroner determined they were not the cause of her death.
Part of Aboriginal people not getting adequately treated sometimes is because its assumed they are on drugs and abusing alcohol, Thompson said. I think for people who work on front lines its difficult, because they do see people who abuse drugs and alcohol. But they need to put that to one side.
Ms Dhus case will also form part of the Aboriginal Health Matters project.
The chief executive officer of the Aboriginal Legal Service, Dennis Eggington, applauded the project.
The issue of how Aboriginal people are being treated within the health system has been of grave concern to many of us over a long period of time and I think its an issue worthy of a royal commission he said.
There should be a better way for the community and the Aboriginal community to have these cases investigated.
Aboriginal people come to us for legal advice, they dont go to a high-profile law firm, but we dont have the expertise or the resources in the area.
* Name has been changed to protect identities