Coroner recommends short-stay unit in Kalgoorlie hospital after Miss T's post-discharge death

The inquest heard the girl may not have died had she been kept for observation. (Supplied: WACHS)

A coroner has recommended that a short-stay unit be created at Kalgoorlie Health Campus following an inquiry into the death of an Aboriginal teenager in 2016. 

The 16-year-old girl was discharged from the campus emergency department on Christmas Eve with signs of infection but no diagnosis. 

She then died of severe septic shock early the following morning. 

The girl, whose identity is suppressed, was referred to in the inquiry as Miss T. 

In her findings, Deputy State Coroner Sarah Linton said Miss T's sister tried to help her when her situation deteriorated back at home.

"When ambulance officers arrived they found no signs of life and signs of rigor mortis."

The coroner said the availability of a short-stay unit, similar to those in other large regional hospitals, could have prevented her death. 

"It was the expert's opinion that had Miss T been kept in the hospital longer for further observation, it is possible her death could have been prevented," the findings read.

Miss T was more open with her symptoms when presenting at the local Aboriginal medical service. (ABC Goldfields: Madison Snow )

Funding for liaison officers recommended 

The coroner also recommended the Health Minister consider funding the availability of 24/7 Aboriginal Liaison Officers at the hospital. 

Coroner Linton said that would enable culturally appropriate support and communication between Aboriginal patients and staff. 

Ten days before her death, Miss T presented at Bega Garnbirringu Aboriginal Health Service and discussed gynaecological symptoms. 

The inquiry heard she did not disclose those symptoms when she presented at the Kalgoorlie Health Campus, where her doctors were non-Aboriginal and Aboriginal Liaison Officers were not made available. 

"I recommend [the minister] give consideration to funding the employment of Aboriginal Liaison Officers ... to provide a seven-days-per-week, 24-hours-per-day culturally appropriate liaison service to facilitate better communication between Aboriginal patients and health staff," the recommendation read. 

Changes supported

Mark Duncan-Smith, WA president of the Australian Medical Association, said the state government should adopt those recommendations.  

Mark Duncan-Smith says the recommendation should be adopted. (ABC News: James Carmody)

"Any expansion of the system or capacity is something that the AMA has been calling on for years for the state government to execute, so I think that is a very appropriate thing to do."

Aboriginal Health Council of WA chair Vicki O'Donnell said Aboriginal Liaison Officers should be made available at all times to help with medical emergencies. 

Vicki O'Donnell says liaison officers are vital to ensure Aboriginal people have access to medical services. (ABC News: Andrew Seabourne)

"Aboriginal people are the best cultural officers to help people navigate the health system," Ms O'Donnell said.

"Our people are very diverse with different language groups and at times English is a second language." 

Government 'aware' of recommendations

The ABC approached Health Minister Amber-Jade Sanderson for an interview but she was not available. 

"The state government is aware of the coroner's recommendations and is committed to providing high-quality, accessible health care in the regions," a spokesperson said. 

The WA Country Health Service also declined an interview. 

"The WACHS feels deeply for Miss T's family," Goldfields regional director Peter Tredinnick said in a statement. 

"While we can never replace their loss, we continue to work closely with the minister's office and the Department of Health on recommendations outlined by the coroner."


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