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The family of Eve Brown, a woman who tragically passed away at a rural clinic lacking adequate resources, believes her death highlights the ongoing health disparities faced by Indigenous Australians.
Eve Brown, a member of the Warrimay community, succumbed to shock on July 2, 2021, following an undiagnosed spleen rupture at the Lightning Ridge Multi-Purpose Centre in northwest New South Wales.
An inquest into her passing revealed that Brown could have survived if the attending doctor had arranged for her transfer to Dubbo Base Hospital, located 350 kilometers away, where CT imaging facilities were available—something the Lightning Ridge facility did not offer.
Initially, Brown exhibited unusual symptoms and was misdiagnosed with an acute urinary tract infection. The coroner noted that the uncertainty surrounding her symptoms should have warranted greater concern and further investigation.
The 42-year-old sought medical attention at the centre at 9:30 a.m. on July 1, but her condition worsened significantly by the early hours of July 2, leading to her untimely death.
A request was made for a flight transfer but could not be arranged until 12.30pm.
Brown suffered a cardiac arrest just before the plane arrived and was declared dead at 1.30pm.
Deputy state coroner Harriet Grahame found the doctor should have referred Brown for CT imaging in Dubbo well before she deteriorated.
Multiple medical experts told the inquest Brown’s symptoms were serious enough and their cause was sufficiently unclear that a transfer should have been ordered on July 1.
An early CT scan might well have revealed the underlying condition that caused the rupture, Grahame said.
“Early transfer … would also have meant (Brown) was in a hospital setting with intensive care and emergency surgery capabilities when her spleen ruptured,” Grahame wrote in her findings.
Grahame recommended the Western NSW Local Health District review its procedures for assessing patients at small rural centres with fewer diagnostic facilities.
The district should also review training for nursing staff to ensure patient progress notes are recorded continuously, not just at the end of a shift.
The legal representative of Brown’s family at the inquest said her case raised profound issues of Indigenous health inequity.
“Aboriginal people continue to experience poorer access to timely, high-quality health care in rural and remote communities,” Naomi Spigelman said.
“We must ensure First Nations patients are able to access properly resourced hospitals … when they need it – no matter where they live.”
The health district said in a statement it would carefully consider the coroner’s recommendations and offered its sincere condolences to Brown’s family.
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