Cairns inquest into deaths of Doomadgee women, including teenager Kaya, hears of commuications failings

A Doomadgee teenager who died in Brisbane after failing to recover two complicated heart surgeries went through six health services in the months leading to her death, an inquest has heard.

IT was striking that a teen who died with rheumatic heart disease (RHD) was sent through six health services in the months before her a death, a medical expert told a Coroner’s Inquest in Cairns on Thursday.

In the months preceding her death, Doomadgee resident Kaya, 17, was treated at hospitals in Doomadgee, Alice Springs, Mt Isa, Townsville and finally Brisbane, where she failed to recover from two high-risk surgeries to try to replace a mechanical heart valve.

The inquest heard that at every one of about a dozen visits at Doomadgee, Kaya’s mother lobbied for surgery.

The inquest before Coroner Nerida Wilson heard Kaya first presented unwell at Doomadgee on July 6 and was transferred to Mt Isa on July 19, with that hospital sending her straight to Townsville.

Northern Coroner Nerida Wilson is presiding over an inquest into the deaths of three women from Doomadgee.

Kaya was ultimately transferred to Queensland Children’s Hospital eight days later, on July 28, where a decision was made not to operate immediately because of the risk of bacterial infection from a wound on her leg.

Adelaide paediatric interventionist cardiologist Dr Andrew Kelly gave evidence communication between health services could have been better – especially from Alice Springs doctors to Doomadgee doctors.

He said doctors had “less than ideal” information.

“Clearly communication between health professionals and continuity of care was important in this case,” Dr Kelly said.

Kaya, 17, presented many times at Doomadgee Hospital in the months leading up to her death in 2020.

“A previous treating professional may have circumvented all of it,” he said.

Dr Kelly said there should have been a phone conversation with her treating doctor in Alice Springs, information should have been available on the RHD register in Queensland and the My Health Record could have been used as a central repository with information including Kaya’s Alice Springs discharge summary.

He said it would have been hard for a non-cardiologist in Doomadgee to detect subtle changes and what they really needed to know was how much she had changed since her Alice Springs admission, and it would have been prudent to have a specialist follow up within a month.

The inquest heard Kaya was given different brands of the drug Warfarin in Doomadgee and Dr Kelly said dosage was not consistent between brands and there was a Queensland Health recommendation against using different brands.

Dr Kelly noted Kaya was very well cared for by her family, particularly her mother, across all six health services.

The inquest into the deaths of Kaya, Betty, 18, and Ms Sandy, 37, will continue on Friday.

The inquest will make findings on the adequacy of the primary health services provided by Gidgee Healing at Doomadgee in providing treatment, education and follow up regarding diagnosis of RHD and the adequacy of the care provided by Doomadgee Hospital.

It will also look at whether there was a delay transferring Kaya to the Queensland Children’s Hospital for surgical intervention, and the adequacy of the care provided to Kaya by the Queensland Children’s Hospital.

Originally published as Cairns inquest into deaths of Doomadgee women, including teenager Kaya, hears of commuications failings