‘Primordial prevention’ key to cutting RHD deaths: Coroner

A coroner has detailed systemic failings that led to three rheumatic heart disease-related deaths within 12 months in a remote Queensland community.
 
WARNING: Aboriginal and Torres Strait Islander readers are advised that this article refers to people who have died.
 
The deaths were the subject of an ABC Four Corners program that aired in March 2022.
 
Three young women, referred to by coroner Nerida Wilson as Betty, Kaya and Ms Sandy at the request of their families, died between September 2019 and September 2020 in Doomadgee in western Queensland.
 
All three deaths were related to rheumatic heart disease (RHD), which disproportionately affects Aboriginal and Torres Strait Islander people in Australia.
 
In March last year, the ABC investigation was highly critical of their treatment, a conclusion also reached by Ms Wilson, who described RHD deaths as ‘100% preventable’.
 
Her report contains 19 recommendations for more effective coordination between health services, as well as for a ‘restorative expert’ to help repair the relationship between the community and healthcare providers.
 
She also suggests clinicians should adopt a ‘high index of suspicion’ for acute rheumatic fever (ARF) and RHD when treating patients in vulnerable communities, and recommends that a program be co-designed to ensure appropriate cultural and safety training for clinicians.
 
All the recommendations have been accepted by Queensland Health.
 
‘The best prognosis to prevent Kaya’s death – indeed all three women – was primordial prevention,’ Ms Wilson wrote.
 
She also detailed failings in communication and planning between different health services, including the handover of RHD patients from the Doomadgee Hospital to Gidgee Healing when the latter became the main primary care service provider in the area.
 
According to Ms Wilson’s report, three patients remained with the hospital for management and bicillin injections, while 47 people were transferred to Gidgee Healing for ongoing care.
 
‘It is now apparent that Gidgee did not have the resources for that undertaking,’ the coroner concluded.
 
A locum doctor was also unable to access medical records when Betty was acutely ill in Doomadgee Hospital.
 
Ms Wilson noted that the coroner’s court was not provided ‘with any example of successful record sharing across multi health organisations or where fragmentation of health services exists’.
 
‘I remain unsure whether such is aspirational or can be properly implemented by collaboration between services,’ she wrote.
 
‘It may be that legislative changes are required.’
 
Aboriginal and Torres Strait Islander communities are among the most vulnerable to RHD in the world, with the disease linked to poverty and social disadvantage.
 
More than 2380 new diagnoses of the disease were reported in Queensland, South Australia, Western Australia and the NT between 2017 and 2021, according to the Australian Institute of Health and Welfare (AIHW). In the same timeframe, the AIHW said 575 deaths were recorded among people having RHD.
 
Of the diagnoses, 1750 were among Aboriginal and Torres Strait Islander Australians, a rate of 75 per 100,000 population.
 
The AIHW figures suggest diagnoses were more common among females than males, with 97 and 53 diagnoses per 100,000 respectively.
 
In the coroner’s report, Ms Wilson noted that individuals and organisations who gave evidence to the coroner acknowledged the deaths of Betty, Kaya and Ms Sandy had ‘identified gaps that were both known and unknown in healthcare at Doomadgee’.
 
‘All say they want to understand and do better,’ she wrote. ‘The time has come for action.’
 
She also referenced the impact of the three deaths and the intense scrutiny that followed.
 
‘Recruitment and retention of staff remains the highest priority for Doomadgee,’ she wrote.
 
‘The fallout from the deaths of Betty and Kaya and Ms Sandy is immeasurable.’
 
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Aboriginal and Torres Strait Islander health acute rheumatic fever RHD rheumatic heart disease