Inquest into the death of Ricky Hampson

Case Number: 2021/235863

Findings Date: 20 August 2024

Magistrate: Erin Kennedy

CORONIAL LAW | failure of diagnosis; perforated duodenal ulcer; insufficient medical investigations; necessity of identification of First Nations status when providing medical treatment; culturally appropriate treatment; natural causes; Dubbo Base Hospital; Western NSW Local Health District; First Nations advisory group; cultural induction training

Responses

Recommendations to	Response
Western NSW Local Health District	Received (PDF, 3.0 MB)
NSW Health	Received (PDF, 3.0 MB)

Recommendations

To the Western NSW Local Health District:

1.    That the Western NSW Local Health District (LHD) consider establishing a standing First Nations consultation and advisory group in liaison with the local Aboriginal community controlled health organisations, such as Dubbo Regional Aboriginal Health Service, to be consulted from time to time.

2.    That the LHD refer its training programs to that consultation group for review and recommendation for revision or additional modules if required.

3.    That the LHD ensure that cultural induction and recurrent training to medical and nursing staff at Dubbo Base Hospital involve face to face engagement with First Nations people from the community of Dubbo and the wider catchment area for the LHD.

3(a): The LHD ensure that cultural induction training, including information specific to the local Aboriginal and Torres Strait Islander community, is provided to all medical and nursing staff who will be employed at the hospital for 6 weeks or more, including staff on a locum basis, as close to the start of their commencement as possible. This training should preferably include face to face engagement with Aboriginal and Torres Strait Islander people from the catchment area of the LHD.

3(b): That the LHD consider whether recurring face to face training in the areas of cultural competence, responsiveness, awareness, humility and safety, can be provided to LHD staff regularly, preferably annually.

3(c): That consideration be given to improving and enhancing mandatory training for staff in respect of:

i. why First Nations patients are a high-risk, vulnerable community;

ii. the scope of practice of Aboriginal Health Workers and Aboriginal Health Practitioners, including the ability of staff to make referrals to Aboriginal Health Workers and Practitioners; and

iii. how Aboriginal Health Workers and Practitioners can be integrated into the clinical practice of doctors and nurses to improve patient experiences.

4.    That consideration be given to including the following information as mandatory when documenting a plan of management as referred to in Appendices A and C to Local Operating Protocol D23/11137:

a. what outstanding investigations are to occur;

b. whether there is a need for medical review;

c. who is required to undertake the medical review; and

d. when the medical review should be conducted during the patient’s stay.

5.    That consideration be given to amending Appendix B of Local Operating Protocol D23/11137 to say "A discharge from the Emergency Department Short Stay Unit (EDSSU) must be approved by a senior medical officer". 

In relation to Dr Nushaj:

6.    That Dr Sokol Nushaj is referred to the Health Care Complaints Commission for investigation and review as to whether he engaged in unsatisfactory professional conduct under the Health Practitioner Regulation National Law (NSW) No 86a in relation to his treatment of Ricky Douglas Hampson including the diagnosis of cannabinoid hyperemesis syndrome on 14 August 2021.

To NSW Health:

7.    That NSW Health consider whether it should amend NSW Health Policy Aboriginal and Torres Strait Islander - Recording of Information of Patients and Clients PD2012_042 to ensure that all medical and nursing clinicians are advised of the Aboriginal or Torres Strait Islander status of a patient to ensure that it is considered in the treatment of such patients.