A coroner has recommended the doctor who fatally misdiagnosed an Indigenous man with complications stemming from excessive cannabis use be referred to the health-care watchdog.
Ricky "Dougie" Hampson died from ruptured stomach ulcers on August 16, 2021, less than 24 hours after he was discharged from Dubbo Base Hospital in western NSW.
The 36-year-old Kamilaroi-Dunghutti man and father of eight was wrongly diagnosed with the drug-related condition cannabinoid hyperemesis syndrome despite lacking key symptoms of nausea and vomiting.
In delivering her inquest findings on Tuesday, Deputy State Coroner Erin Kennedy recommended emergency doctor Sokol Nushaj be referred to the Health Care Complaints Commission for potential unsatisfactory professional conduct.
"Dougie's death was preventable," she told a large group of family members and supporters who turned out to hear the findings.
Mr Hampson's family welcomed the findings, with father Rick Hampson saying the reality is Australian hospitals kill Aboriginal people.
"We define racism by the outcomes and impacts of our mobs experiences and the truth that Australia's healthcare system is rotten to the core," he said.
"Let this inquest be a warning to all doctors in this country.
"You cannot get away with treating patients poorly. You cannot get away with not doing your job properly."
While Ms Kennedy did not find any specific racial bias, either conscious or unconscious, played a part in Dougie's death, she noted Aboriginality was an important factor to consider in delivering health care.
"No real attention was actually given to Dougie's Aboriginality," the coroner said.
"The concept of colourblind treatment does not work in a section of our community that are prone to far worse outcomes."
Dr Nushaj earlier told the inquest "cognitive bias" led him to misdiagnose Mr Hampson, saying he recognised symptoms of agitation and pain and closed his mind to other alternatives.
As a result of the misdiagnosis, Mr Hampson was administered the sedative droperidol which the inquiry concluded masked his pain and made further diagnosis unreliable.
Mr Hampson said Dr Nushaj shouldn't be treating patients, Aboriginal or otherwise, and that justice for his family will be seeing him held accountable.
"These hospitals and doctors keep using fancy words to describe racism - 'cognitive bias, anchoring bias, early diagnostic closure, colour blind bias'," he said.
"They can use whatever term they want at the end of the day, it means blackfellas get killed in the health system - and that's racism."
Among recommendations made by the inquiry were that the Western NSW Local Health District consider establishing a standing Indigenous consultation and advisory group.
It was also recommended NSW Health consider whether it should amend its practices to ensure all medical and nursing clinicians are advised of the Aboriginal or Torres Strait Islander status of patients.
National Justice Project lawyer Karina Hawtrey welcomed the recommendations, including that staff receive face-to-face training in delivering First Nations healthcare.
"Engagement with First Nations people is so important for doctors and nurses to understand the impact that colonisation has had, and continues to have, on First Nations people and the impact that it has on their healthcare," she said.
A Western NSW Local Health District spokesperson said they will carefully consider the findings and recommendations.
"The care provided to Mr Hampson at Dubbo Health Service did not reflect the required standard of care, and we sincerely apologise," they said.
"The Western NSW Local Health District has made changes and improvements to processes following Mr Hampson's death.
"NSW Health offers its sincere condolences to the family and friends."
13YARN 13 92 76
Lifeline 13 11 14
