Inquest into the death of Katrina Lee McGrady

Case Number: 2020/00287551

Date of Findings: 8 December 2025

Magistrate: Deputy State Coroner, Magistrate Joan Baptie

Catchwords: CORONIAL LAW – death of First Nations woman - ruptured berry aneurysm – subarachnoid haemorrhage – endovascular flow diversion - informed consent – communication with family – cultural safety and competency – failure to identify and escalate increasing headaches – multidisciplinary reviews – specialist consultation – health outcomes for First Nations persons – organ donation protocols – end of life care

Responses

Recommendations

To the Hunter New England Local Health District (HNELHD):

1. That the HNELHD consider whether the practice of obtaining informed consent is appropriately adhered to within its surgical units. This recommendation is made within the circumstances of Katrina McGrady’s case, namely the commencement of medication required for a specific procedure in circumstances where all treatment options had not been sufficiently explored with or communicated to the patient, and whether the commenced medication was counter to those other treatment options.
   2. That the HNELHD review its Comprehensive Care: Adult Inpatient Multidisciplinary Care Plan for the purposes of determining:
   a) Whether it is appropriate and fit for purpose for each neurosurgical team or unit; and
   b) Whether it has been sufficiently rolled out to the John Hunter Hospital (JHH)
   3. That the HNELHD recommend to the JHH that it review its practices of raising end of life and organ donation with First Nations families to ensure a discussion of the clinical team occurs as a first step, wherever possible, prior to the issue being raised with the family.