Inquest into the death of Wilfred 'Whippy' Robert Williams

Case Number: 2019/00288607

Date of Findings: 14 August 2025

Magistrate: Deputy State Coroner, Harriet Grahame

CORONIAL LAW – Discretionary inquest – death of First Nations man following emergency presentation to Cowra District Hospital – deceased did not wait during triage assessment and later died at home – assessment of appropriateness of care provided by Western NSW LHD (Local Health District) – failure of nursing staff to escalate presentation to medical officer in accordance with NSW Health policy – health outcomes for First Nations persons – Aboriginal health workers – the need for consultation with Aboriginal communities and organisations in the delivery of culturally safe health care

Responses

Recommendations

To the Chief Executive of the Western NSW Local Health District (WNSWLHD)

1. The WNSWLHD examine developing and implementing an Aboriginal Health Partnership Advisory Consultative Group, whether a single group for the whole of the WNSWLHD or groups for specific communities within the WNSWLHD, considering the Terms of Reference for the Central Coast Local Health District Aboriginal Health Partnership Advisory Council/Committee and the findings in these proceedings.
2. The WNSWLHD, in consultation with Aboriginal Health Partnership Advisory Consultative Group(s), review the efficacy of the cultural competency training it provides to its medical staff (particularly those working in EDs (Emergency Departments)) particularly with respect to factors that may contribute to an Aboriginal patient feeling reticence to remain in a hospital setting or depart before undergoing a medical examination. The review should consider whether the training should mandate a component of face-to face training, which is locally created.
3. The WNSWHLD consider enhancing its Aboriginal Health Worker program by ensuring Aboriginal Health Workers are reasonably available 24 hours a day.