Earlier this month the West Australian coroner recommended police powers to detain people be curtailed, following the death of Balgo artist Maureen Mandijarra at a Kimberley Police Station in 2012.
Her recommendation follows last year’s damning findings into the 2014 death in custody in Western Australia also of Yamatji woman Ms Dhu.
In the post below, Kelly Somers, Michael Wright and Professor Fiona Stanley say health practitioners and services have urgent and systemic lessons to learn from Ms Dhu’s death.
At the heart of that responsibility, they write, is to understand particularly how two critical factors – that Ms Dhu was an Aboriginal person and that she presented under police escort – “distracted health staff from performing their role of listening to the patient and believing what they are told”.
The article interrogates the series of “grave omissions and fatal assumptions” performed by several highly qualified and experienced health personnel” and calls for the health system to both recognise and deal with institutional racism and its ongoing tragic consequences.
It is published as part of Croakey’s ongoing #JustJustice series (see more information below).
Kelly Somers, Michael Wright and Fiona Stanley write
On 2 and 3 August 2014, a young woman presented to the Hedland Health Campus complaining of rib pain. On both occasions she was given painkillers and diagnosed with ‘behavioural issues’ before being released. On 4 August, this young woman presented at the health campus again, this time in cardiac arrest. She died of septicaemia and pneumonia caused by an infection at the site of a rib fracture. She was 22 years old.
There are other facts that are pertinent to the way Ms Dhu was treated by staff at the Hedland Health Campus: she was Aboriginal, of the Yamatji Nanda and the Bunjima family groups, and she presented to the hospital under police escort. Both these facts distracted health staff from performing their role of listening to the patient and believing what they are told.
Police officers appear to approach the people in their custody with disbelief, quite the opposite to how a health practitioner should approach someone in their care. Police are required to balance the health issues of the person in their custody with security concerns. This has serious ramifications for prison and police staff carrying out their duty of care. When health practitioners see people who are in custody, they need to be aware that, from their perspective, their duty of care is to treat the patient. The concerns of police should not interfere with this duty.
Health staff viewed the police as their client, not the patient
Ms Dhu’s treatment by health staff was framed within the police officers’ concern for security. The police uniform was visible when Ms Dhu was waiting in triage and when she was being assessed by nurses and by doctors (police waited in the corridor, outside her treatment cubicle). The task of the health staff became determining whether Ms Dhu was ‘fit for custody’, not to treat her health complaint. The health staff became accomplices in disbelief and viewed the police as their client, not Ms Dhu.
In her report, the coroner presiding over the inquest into the death in custody of Ms Dhu states that, ‘Ms Dhu … [in] presenting at HHC … was escorted by police. This heightened the power imbalance and her dependency. … She was not free to present as a patient, seeking medical assistance, formulating her own questions for the doctors. … Ms Dhu was reliant on police from the Lock-Up and clinicians from HHC. Her reliance upon them heightened their duty of care towards her [our emphasis].’
Yet, the actions of health staff on the first two visits suggests that their concern was to get Ms Dhu out of the hospital as quickly as possible and back into police custody, so much so that standard procedures in the emergency department were not followed.
Nurses and doctors failed to take Ms Dhu’s temperature, they failed to order a chest X-ray (which Ms Dhu’s family submitted was ‘a standard of care’, accepted by the coroner) and they failed to keep Ms Dhu for observation in order to make a proper diagnosis. The coroner found that the conduct of several health staff ‘fell below the standards expected in the emergency department of a public hospital’.
The failing is that the processes were not followed
Health systems have procedures in place so that staff have the best possible chance of picking up the signs of illness. Throughout her report the coroner notes omissions of procedure: ‘the need for … adherence to proper processes’, ‘it becomes even more important to follow proper processes’, ‘there were roadblocks, that is processes, that should have been put in place’.
These procedures are already in place to protect health practitioners from missing something. The expert emergency physician at the inquest stated: ‘You need the process to overcome the deficiencies … we need steps in a process to stop us making understandable errors … it’s about process preventing the error being made.’ These processes all give us the best chance of arriving at the ‘truly objective evidence’ as to a person’s state of health.
The failing is not that these procedures were not in place, but that they were not followed. It is incongruous to read in the inquest report that, time after time, processes were not followed and, yet, that Ms Dhu died of ‘natural causes’. We find nothing natural about a young woman in the care of the state who did not receive adequate medical attention in sufficient time; we find it negligent.
Natural causes can encompass situations where a failure to give treatment is negligent, as the coroner points out, but it is not within the scope of the inquest to find fault on the part of individuals. How can we explain this series of grave omissions and fatal assumptions on the part of several highly qualified and experienced health personnel?
The role of racism in ‘premature diagnostic closure’
The coroner, drawing from expert witness testimony, stated that the clinicians at the Hedland Health Campus suffered from ‘premature diagnostic closure’: they decided on a diagnosis early on (‘behavioural issues’) and stuck with it. Ms Dhu’s symptoms were believed to be because of agitation, not illness, rather than her pain being the cause of her agitation.
The fact of Ms Dhu’s incarceration distracted staff from seeing how ill she was, as the expert emergency physician testified. Is that all? There is nothing in the inquest report that speaks to whether Ms Dhu’s Aboriginality also informed this premature diagnostic closure.
The Aboriginal health expert at the inquest described institutional racism as ‘manifested in our political and social institutions and can result in the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin’.
Doctors, nurses and health managers, along with police, all flatly rejected that cultures of racism existed in their institutions. We believe it is not good enough to be satisfied with a yes or no answer to this question. We know that racism is a problem in our society, therefore, racism will creep into our institutions. Our institutions must actively work to expose it and address it.
Though the coroner found that police relied on the health staff’s misdiagnosis of Ms Dhu to support their belief that she was faking her illness, her recommendations relate mostly to police and legislative changes and only touch on health (exploring legislative change to share information between police and health agencies).
She has recommended thorough and ongoing cultural competency training for police, but not for health staff – never mind how inadequate cultural competency training on its own is.
The Hedland Health Campus conducted its own internal review to understand its failings on each of Ms Dhu’s visits to the health campus. But we are sceptical that any real lessons have been learned given the refusal of management staff to even consider that institutional racism exists.
There have been ongoing efforts to ensure justice for both Ms Dhu and her family. Ms Dhu’s family, the Aboriginal community and the wider society deserve greater accountability by those who work in these systems on our behalf and we need to hold those individuals responsible who failed in their duty of care to Ms Dhu.
That this has not occurred is yet another example of the failure of our system to protect the most vulnerable in our society.
Our procedures in the emergency department and all health contexts are there to ensure that an individual practitioner’s bias does not interfere with the health treatment they give. As individual agents and representatives of our health system, in our own minds is where racism needs to be confronted. If we do not create environments where staff can reflect on how their preconceptions and practices have a negative impact on the health of Aboriginal patients then, sadly, it is very likely another death in custody in similar circumstances will occur.
Kelly Somers is a freelance editor and writer based in Perth. She has an MA in human rights from Curtin University.
Michael Wright is a Yuat Nyoongar man and his family are from an area known as the Victoria Plains, north of Perth, that includes the township of New Norcia. He has held extensive and varied positions throughout his working career, including hospital social work, community mental health and teaching. Michael has a PhD and he currently holds a Fellowship position at Curtin University based at the National Drug Research Institute.
Professor Fiona Stanley, AC FAA FASSA, is Patron of the Telethon Kids Institute, Distinguished Research Professor at the University of Western Australia, and Vice Chancellor’s Fellow at The University of Melbourne.
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