Medical staff failed to give good care to an Aboriginal woman who died in custody, but the doctors and nurses involved are not bad at their jobs, a West Australian inquest has heard.
Ms Dhu, whose first name is not used for cultural reasons, died two days after being locked up at South Hedland Police Station in August last year for failing to pay fines totalling $3622.
The fines stemmed from several offences, including assaulting a police officer.
Ms Dhu, 22, died during her third visit in as many days to the Hedland Health Campus from staphylococcal septicaemia and pneumonia, following an infection in her fractured ribs that spread to her lungs.
Emergency department specialist Stephen Dunjey told the inquest on Wednesday that Ms Dhu’s condition was rare, lethal and almost always misdiagnosed.
“Any opportunity to make a diagnosis and treat her was missed, so I can’t say it was good care,” he said.
“I can understand where the error comes from.
“The system in place did not give her all the chances that she could have had.
“(But) she had an awful condition and she may have died anyway.”
Dr Dunjey said Ms Dhu should have been given a triage level of two on her second visit to the hospital, but it did not mean nurse Alyce Hetherington was bad at her job.
“If you’re asking did Ms Dhu die because she did not get a triage score of two? Definitely not.”
He said Dr Vafa Naderi had made an error by relying on an initial diagnosis of behavioural issues made a day earlier by another doctor.
But he said the decision-making was understandable and one many doctors would make.
Dr Dunjey said Ms Dhu’s illness was not “super obvious” and lacked clues when Dr Naderi saw her.
He said it did not mean Dr Naderi was a terrible doctor, but showed there needed to be a change in processes to avoid future errors.
“You need to put stoppers in the way of this mistake happening,” he said.
Dr Dunjey agreed with other evidence that a chest x-ray would have helped diagnose Ms Dhu’s condition, saying it would have “blown the socks off” medical staff.
Microbiologist David Speers gave evidence that antibiotics would not necessarily have been the recommended treatment for Ms Dhu when she initially visited the hospital because her symptoms were localised, but the medication would likely have saved her.
Dr Speers said Ms Dhu was probably in septic shock hours before she died, but antibiotics would have saved her if they had been given earlier.
“Within an hour or so of her death, I don’t think it would have made any difference at all,” he said.
The inquest continues.