The parents of a Torres Strait Islander boy who died after presenting to Bamaga Hospital multiple times, have called for justice following the release of a damning report from the Queensland Office of the Health Ombudsman (OHO) outlining the events that led up to their son's death.
Charlie Gowa lived in Bamaga in Far North Queensland. At six-years-old, Charlie was proud to be the tallest in his class and was described as a 'happy and healthy' boy whose younger siblings looked up to him.
On January 5, 2017 Charlie woke up unwell, he was vomiting up his breakfast; he had a fever and also had diarrhoea. His parents said he looked weak and his mum took him to the hospital.
They were sent home with Panadol and a re-hydrating iceblock.
That evening Charlie told his mum, Xernona, that he was having trouble breathing, he was vomiting even though he hadn't eaten and he was hot to the touch. His skin was burning so much he would get irritated if his mother touched him.
They went back to the hospital every day for six days. Finally he was admitted to the hospital on January 10. He was then flown to Cairns, where he was put into an induced coma, and then flown to Brisbane.
Charlie's mother Xernona PoiPoi said she tried so hard to get her son the help he needed.
"The hospital would not help him and there was nowhere else we could go," she said.
"These problems have existed for so long and they are still there today. I want better for my family and community."
'I want justice'
On January 14, 2017, nine days after first presenting to Bamaga Hospital, Charlie died after suffering "overwhelming sepsis" stemming from melioidosis - a rare bacterial infection found in tropical areas.
His family had made the heart-wrenching decision to turn his life support off.
Charlie's father Ron Gowa said he wants people to know Charlie's story so there can be change.
"I want justice for my little boy," he said.
"I also want change. Our community needs access to safe healthcare, just like any other Australian community does.
"No family should face the barriers that we faced in trying to save our son."
The Ombudsman's report outlined that Charlie's case is an example of the "ongoing challenges and barriers the hospital and community face", setting out 20 recommendations for improvement, including about cultural competency.
The ombudsman did not find that Charlie's death was preventable, nor that the actions of individuals contributed to his death - instead finding what happened to Charlie was the culmination of widespread systemic issues affecting the hospital and Torres and Cape Hospital and Health Service.
The family's lawyer Anna Talbot, from the National Justice Project said systemic racism is at the heart of this problem.
"We see these issues arise time and again, with First Nations people who are seriously ill being turned away from hospitals," she said.
"Charlie and his family should never have been put in the position of having to beg for basic healthcare. Charlie was so sick, and he just kept getting worse.
"He, his family and his community deserved what most Australians would take for granted: safe and effective healthcare."