Inquest into the death of Eve Liza Brown

Case Number: 2021/191981

Date of Findings: 19 March 2026

Magistrate: Deputy State Coroner, Judge Harriet Grahame

Catchwords: CORONIAL LAW - First Nations - medical - regional health – delayed transfer - Lightning Ridge Multi-Purpose Health Centre - hypovolaemic shock - splenic haematoma - urosepsis 

Responses

Recommendations

To the Chief Executive of the Western New South Wales Local Health District (WNSWLHD):

1. The WNSWLHD review the adequacy of its practices and procedures, with specific regard had to the evidence and findings in this inquest, as regards:
   a. Its instruction to visiting medical officers (VMOs) regarding the VMO consulting an experienced clinician (whether through the Virtual Rural Generalist Service, vCare, or some other means) before admitting a patient to a small hospital facility like the Lighting Ridge Multi-Purpose Centre. This consultation is to include discussion around diagnostic work-up and the appropriateness of a potential transfer to a larger hospital, in lieu of admission, and discussion of planning and timing of transfer. This is particularly so in the case of a patient with suspected bacterial infection who at the time of admission presents with symptoms of infection (e.g. elevated temperature) but otherwise presents as stable.
   b. Consideration of requiring (if not already occurring) random clinical reviews of VMOs’ decisions around admitting an acute patient to asmall hospital (rather than transfer to larger hospital), with such reviews being carried out by clinicians with significant experience in generalist medical care in regional areas and specialist emergency / intensivist experience. This is to guard against lesser standards being accepted at the smaller facility.
   c. Potentially using Eve’s case as part of scenario training for nursing and VMOs around identifying patients at risk of deterioration, transfer and the importance of consultation and discussions before admitting a patient.
2. The WNSWLHD review its practice and procedures to ensure (i) the frequency of vital sign observations being recorded is regularly audited and (ii) ensuring nursing staff (independent of VMOs), in the event frequency of the taking of vital signs and patient monitoring of person in the Emergency Department or admitted as an acute patient is not being undertaken consistently, immediately escalate the matter to the Nursing Unit Manger / Health Services Manager for action (including consideration of whether transfer of a patient with a suspected infection should occur given the capacity issues)
3. The WNSWLHD review the adequacy of its instruction to nursing staff regarding:
   a. The duty of nurses working in smaller regional hospitals, which do not have medical officers rostered on site overnight, to request a VMO attend to examine a patient (rather than leave that to the discretion of the VMO) if the nurse considers that appropriate; and
   b. The importance of nurses entering progress notes into the electronic record system as contemporaneous to the event being documented as is reasonably practicable (rather than entering one electronic record at the end of a shift).