The death of a young, intellectually disabled Aboriginal woman in a Sydney emergency department was the tragic conclusion to a "cluster of mistakes and failures" in a system meant to care for her, says a coroner.
Shona Hookey, 29, died at Campbelltown Hospital on 19 July 2013 as a result of peritonitis caused by a twisted bowel, which was not diagnosed until an autopsy was conducted.
Deputy State Coroner Hugh Dillon on Wednesday handed down his inquest findings, saying he would refer to the Health Care Complaints Commission allegations that a doctor may have discriminated against Ms Hookey on the grounds of her intellectual disability.
Witnesses asserted that Dr Mestridge made statements or asked questions that suggested that Ms Hookey, because of her intellectual disability, should receive a lesser standard of care than would be given to “normal” patients.
Whilst Dr Mestridge “vigorously denied” the allegations, the coroner found it was "more likely than not" that some comments had been made by the doctor; and referred them to the Commission to investigate further and consider whether discrimination had occurred.
"In my view, it is more likely than not that he made the remarks attributed to him or made statements to similar effect," he said.
"It is not for me to say whether Dr Mestrige's remarks and performance on the fatal night deserve professional disciplinary sanction."
In his findings he said that the doctor took her intellectual disability into account in a way that was irrelevant and disadvantageous to Ms Hookey.
Deputy Coroner Dillon also found there had been failings at the Plane Trees Group Home where Shona was being cared for after two carers did not call an ambulance for several hours.
“This indecisiveness raises the question why good, experienced people acted so helplessly in Shona’s crisis,” Mr Dillon said. “Their training appears to have failed them.”
He also found that she was not provided pain relief or fluids while on the ambulance trolley, and she was not sedated to allow for proper readings of her vital signs could be taken.
Additional reporting by AAP