Booth, Yvette and Sandy, Adele and George, Shakaya (“RHD Doomadgee Cluster”)
Deceased
Yvette Michelle Wilma Booth (Betty), Adele Estelle Sandy (Ms Sandy), Shakaya George (Kaya)
Demographics
female
Date of death
2019-09-23; 2020-05-30; 2020-09-12
Finding date
2023-06-30
Cause of death
Betty: cardiac arrhythmia complicating heart failure due to consequences of past rheumatic fever; Ms Sandy: malfunction of artificial heart valve due to clotting on valve surface and elevated blood pressure; Kaya: intracerebral haemorrhage due to coagulopathy (diffuse intravascular coagulopathy, multi-organ failure, and iatrogenic heparin therapy)
AI-generated summary
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventable through better primary health care coordination, screening, and anticoagulation management. Key systemic failures included fragmentation between Gidgee Healing (Aboriginal community-controlled health service) and Doomadgee Hospital with poor information sharing; inadequate follow-up after RHD diagnosis and hospital presentations; failure to escalate cardiac concerns; inappropriate discharge planning (particularly Ms Sandy's discharge on subtherapeutic anticoagulation); delay in cardiac specialist review and surgical intervention for Kaya; and insufficient Bicillin injection adherence. The coroner identified poor communication between services, confusion about roles, cultural safety issues, inadequate staffing, and lack of proper clinical governance as major contributing factors. The inquest heard extensive evidence about systemic barriers: poverty, overcrowding, housing inadequacy, limited health literacy, staff turnover, fly-in/fly-out models, and historical trauma affecting trust. Critical lessons included the need for integrated care coordination, timely specialist referral, proper discharge summaries with clear follow-up plans, explicit responsibility assignment for chronic disease management, and genuine collaboration between government and community-controlled health services.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to share medical records between fragmented health services
- poor communication between Gidgee Healing and Doomadgee Hospital
- inadequate follow-up after RHD diagnosis
- delayed cardiology specialist review
- failure to escalate care when indicated
- inappropriate discharge planning without clear follow-up
- poor Bicillin injection adherence
- inadequate anticoagulation management
- confusion about responsibility between services
- lack of clinical governance at Gidgee
- insufficient resourcing
- staff turnover and fly-in/fly-out models
- cultural safety issues
- lack of documented care plans
- inadequate screening for RHD
- systemic racism and institutional barriers
- overcrowding and poor housing
- limited access to health hardware
Coroner's recommendations
- North West Hospital and Health Service and Gidgee Healing, together with Queensland Health, engage an expert to assess and map healthcare services in Doomadgee to identify duplication, fragmentation, gaps; define roles; develop information sharing guidelines; identify follow-up processes; address accommodation for staff; propose model of care; consider streamlining RHD management with Nurse Navigator role
- Engage restorative expert to repair relationships between clinicians and stakeholder health services
- Engage cultural leader/restorative expert to restore trust between community and healthcare providers (subject to community endorsement)
- Community consider appointing independent Community Liaison Officer to act as conduit between Health Council and Health Service Providers
- Community through CLO develop model for community support to health services including cultural training and development of community members to assist with acute patient care (guardian angel service)
- Consider identifying and training willing community members in CPR to develop greater community capacity for emergencies
- Queensland Health consult with Doomadgee Shire Council to provide funding for environmental health officer to address primordial RHD risks
- Community develop local RHD action plan in consultation with school, Gidgee, and Doomadgee Hospital with actionable targets aligned with Ending Rheumatic Heart Disease Queensland Strategy 2021-2024
- Queensland Health consider funding laundromat and showering facilities project or approach Orange Sky for laundry/shower truck service
- North West Hospital and Health Service review discharge plan processes to ensure discharge plans sent to relevant providers; address inappropriate prescribing of Clexane when surgery not scheduled; review doctor coverage and rostering to ensure appropriate medical coverage and timely electronic record access; review lessons learned and apply to other communities
- Queensland Health with First Nations community consider whether Ryan's Rule needs adaptation for cultural appropriateness
- Queensland Health determine most effective approach to identify ARF and RHD in high-incidence communities
- RHD Register and Control Program clarify purpose and function; ensure clinicians understand value for care coordination; explain purpose to patients and families
- Queensland Health through RHD Register and HHS identify strategies to encourage high-risk index of suspicion for ARF/RHD in prevalent communities
- Queensland Health consider project guidelines for agreed rollout of ACCHO in communities currently serviced only by Hospital and Health Service; ensure services mapped and model of care identified prior to ACCHO commencement
- Queensland Health, NWHHS, and Gidgee Healing consider adopting Matrix for Identifying, Measuring and Monitoring Institutional Racism within Public Hospitals and Health Services
- Queensland Health, NWHHS, and Gidgee Healing consider improvements to clinical note recording to avoid implicit negative cultural and racial connotations
- Stakeholders co-design with Doomadgee community program for training clinicians and staff in cultural safety with understanding of matters specifically relevant to Doomadgee
- Coroners Court Queensland recruit cultural capability officer to provide service to First Nations families at inquest and advice to coroners on issues touching on First Nations people
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