The tragic death of Eve Brown, a Warrimay woman, highlights the ongoing health disparities faced by Indigenous Australians, particularly in rural areas. Her family’s sorrow underscores a broader systemic issue that demands attention and action.

Eve Brown passed away from shock on July 2, 2021, due to an undiagnosed ruptured spleen. This occurred at the Lightning Ridge Multi-Purpose Centre in northwest New South Wales, a facility lacking the necessary equipment for a proper diagnosis. The inquest into her untimely death revealed that a transfer to Dubbo Base Hospital, located 350 kilometers away, for CT imaging might have saved her life. Unfortunately, such resources were unavailable at the Lightning Ridge center.

Initially, Brown sought medical help at the center on July 1, presenting symptoms that were mistakenly attributed to an acute urinary tract infection. However, the coroner noted that the ambiguity surrounding her condition should have raised more serious concerns and prompted further investigation.

As her health deteriorated in the early hours of July 2, a flight transfer was requested. Despite the urgency, it was not arranged until 12:30 p.m., far too late to save her life. This delay underscores the critical need for improvements in healthcare infrastructure and access in remote communities.

Eve Brown’s story serves as a poignant reminder of the profound inequities still faced by Indigenous Australians, particularly in healthcare, and calls for immediate reforms to prevent similar tragedies in the future.

A request was made for a flight transfer but could not be arranged until 12.30pm.

Brown suffered a cardiac arrest just before the plane arrived and was declared dead at 1.30pm.

Deputy state coroner Harriet Grahame found the doctor should have referred Brown for CT imaging in Dubbo well before she deteriorated.

Multiple medical experts told the inquest Brown’s symptoms were serious enough and their cause was sufficiently unclear that a transfer should have been ordered on July 1.

An early CT scan might well have revealed the underlying condition that caused the rupture, Grahame said.

“Early transfer … would also have meant (Brown) was in a hospital setting with intensive care and emergency surgery capabilities when her spleen ruptured,” Grahame wrote in her findings.

Grahame recommended the Western NSW Local Health District review its procedures for assessing patients at small rural centres with fewer diagnostic facilities.

The district should also review training for nursing staff to ensure patient progress notes are recorded continuously, not just at the end of a shift.

The legal representative of Brown’s family at the inquest said her case raised profound issues of Indigenous health inequity.

“Aboriginal people continue to experience poorer access to timely, high-quality health care in rural and remote communities,” Naomi Spigelman said.

“We must ensure First Nations patients are able to access properly resourced hospitals … when they need it – no matter where they live.”

The health district said in a statement it would carefully consider the coroner’s recommendations and offered its sincere condolences to Brown’s family.

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