Ricky Hampson lost his son Dougie six months ago.
He still feels the pain deeply every day.
“He was a devoted father. He was a very old soul. Very humble. The sort of bloke that would do anything for you,” he said of the 36-year-old Kamilaroi-Dunghutti man.
Dougie's mother Lydia Chatfield also feels the loss profoundly.
"He was just our pride and joy. You know, you have your first child. He was everything. Everything."
The loss is eating away at the couple.
The tragic details occupy Mr Hampson’s every waking thought, increasingly so as he’s learned more and more about how his son died shortly after being discharged from hospital in the regional NSW town of Dubbo.
A "popping" sound
It was a Saturday in August last year. Dubbo was experiencing a COVID outbreak at the time.
Ricky Hampson, loved by his family as "Dougie", had been tested earlier in the day but was yet to receive his result.
Around 5pm, in severe pain, he went to emergency. He told staff he’d heard a popping sound, like a tear inside him.
“They kept him there for 19 hours, just monitoring,” Mr Hampson told NITV's The Point program.
“No Senior Medical Officer ever examined him and they ended up releasing him the next day, just before lunch.
“He went back to the house where he was staying at the time. And they tried to wake him up the next morning and he was passed.”
Since then, Mr Hampson has doggedly been asking questions and seeking answers about what happened.
“They never took (any) scans, no X-rays or anything like that,” Mr Hampson said.
“We spoke to the director up there of the hospital, or (one of) the doctors, and he said that if [they had] done a simple scan, [they would have had] him in surgery that night and he would be here today.”
Review confirms "bias" in case
Within 24 hours of his release, Dougie had died from two perforated ulcers.
An internal hospital investigation late last year confirmed the family’s fears.
"It's just plain discrimination and bias. It’s rocked us, it really has. The whole family.”
The report by Western NSW Local Health revealed the hospital staff had made up their minds early, with bias, based on Mr Hampson’s presentation and history.
“They admitted to treating him with bias because of his presentation, the way he looked because he admitted to drug use,” Mr Hampson said.
“They thought well here’s another black fella off the streets. It's just plain discrimination and bias. It’s rocked us, it really has. The whole family.”
The Serious Adverse Event Review report by Western NSW Local Health found: "The Review team considered there was 'early diagnostic closure' and 'anchoring bias' related to the patient's presentation, history of cannabis use and subsequent management".
Training, cultural awareness program underway: Western NSW Health
In a statement to The Point, Western NSW Health chief executive Mark Spittal said Mr Hampson's death has been referred to the coroner, and the heath service was assisting with the Coronial process.
It did not say whether anyone has been disciplined over Mr Hampson's treatment.
"We offer our sincere condolences to the family of Ricky Hampson Jnr," he said.
"We are committed to listening, learning and making any changes necessary to ensure everyone receives the highest standard of care at our emergency departments."
It added that: "A training program for clinical staff to reinforce clinical reasoning skills is underway, along with an active cultural awareness program that is reinforced by the continuing recruitment of Aboriginal staff to work at all levels of WNSWLHD's service".
It's little comfort to Mr Hampson's mother Lydia Chatfield.
"I've got no words for them, I haven't," she said.
"They took my boy. He was my best friend. They took him. They just could not take care of my son."
Family wants to set up foundation
The family has called for an inquest, and wants to set up a foundation to help other families whose loved ones have also been let down by the health system.
Mr Hampson said the family was working with the National Justice Project.
“All we can do now is just fight for his justice.That's what we want. We want the world to know what is still going on here. And it's got to stop. It’s really got to stop," Mr Hampson said.
Systemic change needed: Australian Indigenous Doctors' Association
The Australian Indigenous Doctors’ Association said bias and discrimination is rife within the health sector, as well as other areas such as education and retail settings.
AIDA director and Wotjobaluk man Dr Glenn Harrison called for systemic change, including 24-hour patient access to Aboriginal hospital liaison workers and greater links with Aboriginal Community Controlled Health Services.
“Biases from a health workforce means that you can’t actually give the appropriate level of care that a patient needs,” Dr Harrison said.
“If you have got a health system that is regularly showing bias and poor outcomes for Aboriginal and Torres Strait Islander patients, then you have really got to consider your workforce and how you can actually change that cultural awareness, cultural safety and actual model of care that you are providing for your patients.
“Which is what the health workforce and the health service is for at the end of the day.”
Western NSW Local Health District said it had seven Aboriginal health practitioners at its Dubbo Health Service, who work on a rotating roster in the emergency department seven days a week.
* You can view the full story on NITV's flagship current affairs show The Point, which airs on NITV at 7.30pm tonight and later on SBS.