Coroner: Earlier Transfer Could Have Saved Mother of Three in Remote Hospital
A coroner has determined that a 42-year-old mother of three, Eve Brown, could have survived if a medical transfer from a remote hospital in Lightning Ridge had been initiated sooner. Ms. Brown died on July 2, 2021, while awaiting transfer to Dubbo. An autopsy identified the cause of death as hypovolaemic shock resulting from a hidden spleen injury, which tragically led to sepsis.
Inquest Findings
Deputy State Coroner Harriet Grahame concluded that it was “more probable than not” that Ms. Brown would have survived had her transfer been expedited the day prior to her death. The inquest revealed that Ms. Brown experienced "extreme suffering" in the hours before her death and that the Lightning Ridge healthcare facility had inadequate resources. Coroner Grahame noted that a proper initial assessment should have prompted immediate discussions about transferring her to a facility equipped for scanning.
“It was more probable than not that Ms. Brown would have survived had her transfer been expedited the day prior to her death.”
Missed Opportunities and Medical Challenges
The coroner identified several "missed opportunities" in escalating Ms. Brown's care. These included a delayed doctor's review overnight. During the inquest, medical professionals discussed the difficulties of diagnosis and care in a rural setting. Dr. Ifran Hakeem initially treated Ms. Brown for an upper urinary tract infection. A nurse, Jamie Brizuela, testified that she was uncertain how to contact Dr. Hakeem for assistance as Ms. Brown's condition deteriorated overnight. A transfer request to the Royal Flying Doctor Service was made on July 2, 2021, but Ms. Brown experienced cardiac arrest and died before she could be airlifted.
Family Advocacy and Calls for Change
Trina Brown, Ms. Brown's mother, stated she would continue advocating for improved healthcare services in Lightning Ridge, including the installation of a CT scanner. She expressed hope that the inquest would lead to changes that could prevent similar tragedies.
Expert Perspective
Rachel Christmas, president of the Rural Doctors Association of NSW, acknowledged the challenges of providing healthcare in rural areas due to limited facilities and staff. She indicated that placing a CT scanner in every town might not be financially viable but stressed the importance of training nursing and medical staff to recognize seriously unwell patients and the necessity of further investigations.
Rachel Christmas, president of the Rural Doctors Association of NSW, stressed the importance of training nursing and medical staff to recognize seriously unwell patients and the necessity of further investigations.
Coroner's Recommendations
Coroner Grahame issued several recommendations to the Western NSW Local Health District. These included modifications to medical practices and procedures, and the use of Ms. Brown's case as a scenario for training visiting medical officers to enhance their ability to identify deteriorating patients and understand the importance of timely transfers. A health district spokesperson extended condolences and stated the findings and recommendations would be carefully considered.