rheumatic heart disease

A coronial inquest examining the deaths of three Indigenous women in the north-western Queensland town of Doomadgee has begun its next stage in Cairns today, with family members saying “systematic, ingrained racism” was a contributing factor.

The three young women, whose families requested they be referred to as Kaya, Ms Sandy and Betty, died in 2019 and 2020 from complications associated with rheumatic heart disease (RHD).

The inquest was triggered after an ABC Four Corners program revealed the women died after being sent away from the Doomadgee Hospital.

Last month the inquest began in Doomadgee, where family members told the court the women were not properly examined and said the town needed more doctors who live long-term in the community.

During questioning, Counsel Assisting the Coroner, Melina Zerner, told the court that between August 2021 and 2022, only 4 per cent of RHD patients in Doomadgee were receiving all of their prescribed injections.

Kaya’s mother, Weenie George described the years her daughter lived with RHD, and the painful injections she endured.

She told the court Kaya regularly took her medication and brought it with her when she went to boarding school and on a holiday to the Northern Territory, just before she became ill.

Ms George described first seeing her daughter in the NT, after several weeks being stuck because of border closures.

“She wasn’t looking good at all… swollen, short of breath,” she said.

Alec Doomadgee, who was a father figure to Kaya, said she was very responsible with her health and he was sure systemic racism played a part in the women’s deaths.

He said when he spoke to Kaya in June 2020, after she had visited her boyfriend in the NT, he could tell something was wrong.

“She said: ‘I’m not well Dad’.”

‘I had faith in the system’

He said after being discharged from Alice Springs Hospital, Kaya was taken to a clinic in Doomadgee.

“I thought they’d fly her out… I was pretty comfortable, I had faith in the system,” he said.

Mr Doomadgee became choked up and wept while describing the following weeks where he said he had to fight for Kaya to be transported to Mt Isa, Townsville and then Brisbane hospitals, where she underwent several surgeries but never recovered.

He said he’d like to see a “guardian angel” system established in health systems, where someone independent from the health service could advocate for Indigenous patients.

He said this could help address the imbalance of power inherent in health systems, especially in Indigenous communities.

“It’s systemic, ingrained racism that our country is built on… white people are the authority figures in the community,” he said.

The former acting manager of the RHD register, and registered nurse Kylie McKenna, told the court diagnosis and treatment were both challenging in Indigenous communities.

Nurse Kylie McKenna leave court after giving evidence at the Rheumatic Heart Disease inquest — Nurse Kylie McKenna gave evidence about the difficulty of getting people in Indigenous communities treatment for rheumatic heart disease.(ABC News: Brendan Mounter)

She said while there were clear guidelines to diagnose RHD, symptoms weren’t uniform, and some tests could only be done when the person was symptomatic.

“It’s a lot of criteria to be met… a lot [of cases] are probable or possible,” she said.

Ms McKenna also described the pain and burden of the only available treatments for RHD: monthly bicillin injections or twice daily oral penicillin — both could be given for a minimum of five years or for a person’s entire life if required.

She said injections were the most common form of treatment but could be extremely uncomfortable.

“It’s like getting toothpaste administered through a very large needle,” she said.

Ms McKenna said it was crucial for staff to be well trained and known in the community to make sure treatments were administered regularly.

“You need people who understand it’s a painful injection,” she said.

She said staff also needed to be trained in pain reduction techniques as well as cultural issues around shame and the other life commitments many patients have.

Three women sit at a table and chairs outside a brick hospital building. The photo is taken between the bars of the fence. — Family members told the court the women were not properly examined at Doomadgee Hospital.(Four Corners: Louie Eroglu ACS)

A 19-year-old Aboriginal man’s death would likely have been prevented if multiple state authorities had not failed to arrange a life-or-death medical appointment, according to the WA state coroner.

Aboriginal and Torres Strait Islander readers are advised that this story contains an image of a person who has died.

Mr Yeeda, whose first name is being held for cultural reasons, died on May 3, 2018 at the West Kimberley Regional Prison near Derby.

The Miriuwung Gajerrong man was six weeks away from being released when he died from rheumatic heart disease after a game of basketball at the facility.

“He was looking forward to life,” said his mother Marlene Carlton, who released a written statement through the National Justice Project.

“He wanted to do his time so he could come out and live with his dad on a station and work with horses.”

According to the state coroner’s findings released this week, Mr Yeeda had rheumatic heart disease and had a referral to see a cardiologist about getting heart surgery.

However, an appointment for Mr Yeeda was never made.

Surgery likely would have prevented death

Based on an inquest held in September, the WA coroner concluded the young man would likely have been told he needed urgent heart surgery if he had made the appointment.

“If Mr Yeeda had undergone aortic valve replacement surgery, it is likely that his death would have been prevented,” a summary statement from the coroner said.

A picture of Mr Yeeda smiling on a horse, holding his hat in the air with Kimberley rock formations behind him — The WA coroner has found Mr Yeeda’s death would likely have been prevented if not for failings in the health and justice systems.(Supplied: National Justice Project)

The coroner added that the WA Country Health Service bore the ultimate responsibility for the referral not being actioned, while the Department of Justice missed an opportunity by not having a computer-based tracking system to make sure urgent prisoner referrals were not missed.

“The WA Country Health Service feels deeply for the deceased’s family,” a spokesperson for the service said.

“While we can never replace their loss, we are working closely with all concerned on the recommendations outlined by the coroner.”

The Department of Justice said it acknowledged the findings of the coroner.

“All deaths in custody are taken seriously and systems and processes will be reviewed in light of the coroner’s recommendations,” the department said in a statement.

WA Cardiology also missed a number of opportunities to assist, according to the coroner.

The service has been contacted for comment.

Coronar’s recommendations

The coroner recommended that the Department of Justice work together with the country health service to improve the exchange of information about the status of referrals, and address tracking system delays created by a lack of resources in the department.

The third and final recommendation was for the department to investigate the feasibility of creating a list that would alert prison officers if an inmate was unfit for sport or work.

Mr Yeeda had been in custody for about one year when he died, having been taken into the facility on May 5, 2017.

He required regular medication and monitoring for heart damage he experienced as a young child, when he had rheumatic fever.

He had surgery for an aortic valve repair when he was a child but it was not a cure for his rheumatic heart disease.

Mr Yeeda was supposed to have monthly penicillin injections but was occasionally resistant to having them.

Arrangements for Mr Yeeda to have heart surgery had previously been made in 2015, but those surgeries were canceled because consent had not been provided by him, or on his behalf.

“However, the fact that there had been no past consent did not mean there would be no future consent,” the coroner wrote.

According to the findings, Mr Yeeda had agreed on December 5, 2017 to see the visiting cardiologist but the appointment was not made.

He died about five months later.

Ms Carlton said her son’s death should have been prevented.

Concerns about racism, lack of cultural care

“There was a lack of communication between the prison and me – if anything happened to him, they should have called me, but they didn’t,” Ms Carlton said.

“There should be a better system to monitor their [the inmates’] health, and they need people in the prison who understand Indigenous culture and health [requirements].”

George Newhouse, the principal solicitor and director of the National Justice Project, said more needed to be done to ensure culturally safe health care in prisons.

“The coroner has failed to address the systemic racism in WA’s justice and healthcare systems which led to Mr Yeeda’s death,” Mr Newhouse said.

Professor Juanita Sherwood, a Wiradjuri woman and board member of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, said prison staff should have followed national guidelines for managing rheumatic heart disease.

“These guidelines are easily accessible, and prison and health staff should have known better because we all know it’s a big issue for Aboriginal and Torres Strait Islander communities that needs to be managed well,” she said.

“The lack of treatment and follow-through reveal a negligent treatment of Mr Yeeda.”

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