Inquest into the death of Wilfred Whippy Williams

Contributing factors

• Failure to notify medical officer of triage category 2 presentation
• Failure to notify medical officer of patient departure before assessment
• Incomplete triage assessment (blood glucose not measured)
• Patient's fear and aversion to hospital settings related to past involuntary psychiatric admissions
• Lack of cultural safety in ED environment
• Aboriginal status not accurately recorded in electronic health record
• No Aboriginal Health Worker available afterhours
• Limited engagement with patient and family due to absence of culturally appropriate care
• Lack of communication from GP surgery to ED regarding patient's expected presentation
• Poorly managed chronic diabetes with dietary non-compliance
• Pneumonia as precipitant of diabetic ketoacidosis
• Respiratory system vulnerability due to smoking history

Coroner's recommendations

1. The WNSWLHD examine developing and implementing an Aboriginal Health Partnership Advisory Consultative Group, whether a single group for the whole of the WNSWLHD or groups for specific communities within the WNSWLHD, considering the Terms of Reference for the Central Coast Local Health District Aboriginal Health Partnership Advisory Council/Committee and the findings in these proceedings
2. The WNSWLHD, in consultation with Aboriginal Health Partnership Advisory Consultative Group(s), review the efficacy of the cultural competency training it provides to its medical staff (particularly those working in Emergency Departments) with respect to factors that may contribute to an Aboriginal patient feeling reticence to remain in a hospital setting or depart before undergoing a medical examination. The review should consider whether the training should mandate a component of face-to-face training, which is locally created
3. The WNSWLHD consider enhancing its Aboriginal Health Worker program by ensuring Aboriginal Health Workers are reasonably available 24 hours a day