Inquest into the death of Shona Hookey

29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (twisted bowel)

Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at her group home delayed calling an ambulance despite hours of severe distress, the emergency department misclassified her triage category (Category 3 instead of Category 2), she was left on an ambulance trolley for two hours without pain relief or fluids, a doctor failed to escalate her care appropriately and appeared to weigh her disability negatively in treatment decisions, and resuscitation efforts were delayed. The coroner found the death likely preventable if appropriate assessment and escalation had occurred early. Key lessons include: disability should never be a factor in treatment decisions, contemporaneous record-keeping is essential under pressure, early recognition of deterioration and escalation protocols must be followed, and systems must support safe care even during resource crises.