Sitting on the witness stand in the Doomadgee courthouse, Paula Booth spoke of the days leading up to the death of her sister Betty.
Warning: Aboriginal and Torres Strait Islander readers are advised that this article contains images of people who have died
Betty suffered from rheumatic heart disease (RHD), a treatable condition that now almost exclusively affects Aboriginal Australians.
"They gave her Panadol and sent her away," Ms Booth said.
The next day, Betty died. Hers is one of three RHD deaths that occurred in the remote Queensland community from 2019 to 2020.
Other women who died included Kaya George and Adele Sandy.
The deaths, which were investigated by Four Corners earlier this year, are now the subject of a coronial inquest that launched on Monday.
The first sitting of the inquest heard from families of the deceased.
The use of Panadol for the treatment of emergency health conditions, poor communication, long waiting times at Doomadgee Hospital, and the need for better staff, were flagged by families as issues.
Stop this 'Panadol nonsense'
Ms Sandy's husband, Edgar, told the inquest the use of painkillers to treat patients that presented at Doomadgee Hospital with severe health conditions was still common.
"My brother has a heart problem and went to the hospital the other day with chest pains and they gave him painkillers and told him to go home," he said.
Relatives of Betty agreed.
"They're still handing out Panadol through the grate," Ms Booth said.
"We need to put a stop to this Panadol nonsense," Betty's brother told the courtroom.
Calls for better staffing
Doomadgee Hospital is currently staffed by different doctors that fly in and fly out.
A relative of Betty told the inquest inconsistencies occurred because of fly-in, fly-out doctors.
"You see one doctor one day and you go back and see a different doctor the next day and you have to give all your information again," the relative said.
Mr Sandy said the community needed a more permanent service.
"We need better staff at the hospital," he said.
Communication with staff as well as the treatment of Aboriginal patients were also highlighted by the families as areas that needed improvement.
"My brother will go in and sit in the waiting room and staff won't ask him if he's okay," Mr Sandy said.
Martin Evans, uncle to Betty, said more community engagement was needed.
"Health has to do better," he said.
"They should call a meeting with the community, sit down and talk to all of us, so that there's no more pointing fingers at each other.
"We do it with the Royal Flying Doctors."
We need doctors who 'stay here'
Mother of Kaya, Weenie George, spoke to the ABC prior to the inquest.
She said greater investment was needed to entice a doctor to the community on a more permanent basis.
"The staff here, sometimes you feel like they're getting sick of you coming in.
"We need doctors who come in and stay here in the community."
Monday's hearing was the first of three sessions to be held as part of the coronial inquest.
The next session will run for four days, starting on August 15 in Cairns.
The third and final session will be held in Cairns on September 12 and will run for three days, after which submissions will be accepted.
"At the end of the day, we need change," Ms George said.
