The head of the National Justice Project has said the failings that led to the death of Miss T in Kalgoorlie are some of the worst he has seen.
The 16-year-old Aboriginal girl was sent home from hospital despite signs of an infection on Christmas Eve in 2016.
She was found hours later by her sister vomiting and convulsing in septic shock and died before an ambulance could arrive.
A coronial report was released at the end of last year.
Human rights lawyer George Newhouse said the system failed Miss T.
"A lot of Aboriginal or Torres Strait Islander people come to us for support when they've been mistreated by the health system, but this is one of the worst I've seen," Mr Newhouse said.
Grounds for legal action
He said Miss T's family have grounds for legal action against the WA Country Health Service (WACHS) and could be eligible for damages or compensation.
"On the face of the evidence that I've seen and the findings in the report, there does seem to be a case against the WA Country Health Service," he said.
Mr Newhouse said the tragedy shared similarities with that of Ms Dhu, Naomi Williams and, more recently, Dougie Hampsen.
"We need to confront the truth so we can address the systemic problems of bias and prejudice in our health services as a nation," he said.
The Health Minister and the WACHS both declined interviews and issued statements saying they were aware of the findings.
Mr Newhouse said that's not good enough.
"This isn't the first time that an Aboriginal person has died like this in WA and in won't be the last, until the coroner's findings are implemented."
The coroner recommended the Health Minister create a short-stay unit at Kalgoorlie Health Campus and fund 24/7 availability of Aboriginal liaison officers.
Levels of racism in the system
Paul Stewart from the Lowitja Institute, the national institute for Indigenous health research, said tragedies like this have ripple effects throughout the Aboriginal community.
He called on the Health Minister to commit to the coroner's recommendations.
"It's an opportunity for the WA government to really ask themselves if these recommendations need to be rolled out across the state, so that we don't have another case of Miss T happening in another regional town," Mr Stewart said.
But he believes the recommendation of Aboriginal liaison officers is only part of the solution.
"We need to grow our Aboriginal and Torres Strait Islander workforce, but we also need to equip the broader health workforce with the right training and education to ensure that they deliver good quality care in a culturally safe manner," he said.
