Three years after Dougie's fateful hospital visit a court has determined his death was preventable. or signup to continue reading Kamilaroi Dunghutti man Ricky Hampson Jr, known to family and friends as Dougie, died less than a day after being discharged from Dubbo hospital in NSW on August 15, 2021. Handing down her findings in a courtroom filled with Dougie's loved ones on Tuesday, August 20, Deputy State Coroner Erin Kennedy concluded he would have lived if he received adequate treatment.
"Look at the amount of people here...
it's a beautiful tribute to how important Dougie was in your lives," she told the court. "Preventable death extends way beyond the person to the family and loved ones who are left. "[Dougie] went to hospital.
He didn't like hospital. And he didn't receive adequate care and he was lost to them." The finding follows into the 36-year-old father-of-eight's death held in Dubbo in March.
The court heard from the doctors and nurses who attended to Mr Hampson Jr during his stay, Indigenous health experts, the Western NSW Local Health District and Dougie's loved ones. "It is very clear that [Dougie] did have mental health and substance abuse issues which did lead him to some challenges, including with the law..
. however these are all issues he faced head on and worked to address," Deputy State Coroner Kennedy said. " and one who brought great joy to his parents and siblings.
.. Dougie was vibrant, he was a real personality.
"What is hoped, and what Dougie will hopefully promote, is change for the future." Deputy State Coroner Kennedy said at the time Dougie presented to the emergency room it was struggling with understaffing, a large number of inexperienced doctors and all the chaos of COVID-19. Just after 5pm on August 14, 2021, Mr Hampson Jr visited Dubbo Hospital with a highly elevated heart rate and "10 out of 10" pain after feeling something "pop" in his stomach.
The nurse who triaged him said he was "writhing with pain" in the waiting room. Dr Lisa Hu, an inexperienced doctor assigned to his care, took a brief history, examined his abdomen and came to an impression of "undifferentiated abdominal pain". She noted what she found, including the popping sensation and spoke to her supervisor Dr Sokol Nushaj.
Although he had not examined Mr Hampson Jr, he suggested he could be suffering from Cannabinoid Hyperemesis Syndrome (CHS) - a rare condition that only occurs in daily long-term users of marijuana. Although Mr Hampson Jr had smoked "a couple of cones" that morning, it was not known to Dr Nushaj when he made the diagnosis. Dr Nushaj said he first considered the diagnosis when he saw Mr Hampson Jr being wheeled into the isolation area of the hospital.
Notably, Mr Hampson Jr was not suffering nausea or vomiting, two main symptoms of CHS. There was no further investigation of the "popping" sensation Mr Hampson Jr reported and he was not given an x-ray or CT scan. Dr Nushaj now acknowledges .
Deputy State Coroner Kennedy agrees the diagnosis was unreasonable. She said as a result of the misdiagnosis Mr Hampson jr was given unnecessary medication which masked his symptoms and made it hard for other doctors who examined him that evening to recognise what was going wrong. "I am satisfied that this was not a diagnosis available to Dr Nushaj," she said in her findings.
She has recommended Dr Nushaj be referred to the healthcare complaints commission. The next morning, August 15, Mr Hampson Jr's heart rate was still high and his pain was increasing but he was not seen by a doctor at all. He stayed in the hospital until just after midday, when he was discharged.
He was still in "obvious discomfort" when he walked out. It is unclear exactly where Mr Hampson Jr went when he walked out of hospital but later that afternoon he arrived back at a relative, Marshall Peachey's, house by taxi. Mr Peachey - who Mr Hampson had been staying with - said he had no idea Mr Hampson had been at hospital until he came home.
The living room of Mr Peachey's house was , at around 3:30am on August 16. At about midday, Mr Peachey went into the living room to check on Mr Hampson Jr. He wasn't breathing.
Mr Peachey tried to do CPR on him but it was too late. He had been dead for some time. Mr Hampson Jr's family had no idea he had been in hospital until they received the news he had died and his body was brought into hospital.
An autopsy later found two perforated ulcers in his stomach and four litres of fluid in his abdominal cavity. Although serious, it was a condition that could have been treated, the coroner concluded. Deputy State Coroner Kennedy recommended the health district review their discharge procedures to ensure emergency patients are seen by a senior doctor before being discharged.
Another failing of the hospital, Deputy State Coroner Kennedy found, was the fact . She said the fact "no real consideration" was given to his background meant health professionals ignored red flags they might have picked up on if it were taken into account. Giving evidence during the inquest, one expert said .
"The concept of colour blind treatment doesn't work when it comes to a part of our population which is prone to far worse outcomes than the general population," Deputy State Coroner said. She noted that since Mr Hampson Jr's death "some steps" have been taken by the hospital to better educate staff around cultural safety but "more needs to be done". In her recommendations, she called on the health district to create an advisory body made of local Indigenous people who can review staff training.
She said the district should provide face-to-face cultural training to all hospital workers, including locums. "Dubbo Hospital should be supported to become a centre of cultural excellence," she said. "What is hoped, and what Dougie will hopefully promote, is change for the future.
" Allison Hore is a journalist with the Daily Liberal. Allison Hore is a journalist with the Daily Liberal. Advertisement Sign up for our newsletter to stay up to date.
We care about the protection of your data. Read our . Advertisement.
