National

Rural doctor missed vital call in Indigenous death

Mar 21, 2026

A hospital sign — Medical imaging could have saved Indigenous woman Eve Brown's life, an inquest into her death found. -AAP Image

The family of a woman who died in an under-equipped rural clinic say her death is an example of the health inequities still experienced by Indigenous Australians.

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Warrimay woman Eve Brown died of shock on July 2, 2021, after an undiagnosed spleen rupture at Lightning Ridge Multi-Purpose Centre in northwest NSW.

The inquest into her death found she would likely have survived had the centre's doctor requested she be transferred to Dubbo Base Hospital, 350km away, for CT imaging, which wasn't available in Lightning Ridge.

Ms Brown presented with unusual symptoms and was initially diagnosed with an acute urinary tract infection but uncertainty about her condition should have prompted more concern, the coroner found.

The 42-year-old first presented to the centre at 9.30am the day before she died but deteriorated in the early hours of the morning on July 2.

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

Ms 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 Ms Brown for CT imaging in Dubbo well before she deteriorated.

Multiple medical experts told the inquest Ms 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, Ms Grahame said.

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

Ms 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 Ms 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 Ms Brown's family.

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