A doctor who misdiagnosed an Indigenous man as suffering a drug-induced condition before he later died in excruciating pain due to perforated abdominal ulcers should be referred to the health watchdog, a coroner has found.
The NSW Coroner’s Court on Tuesday handed down its findings into the death of Ricky “Dougie” Hampson, who died in August 2021 less than 24 hours after being discharged from hospital.
The court heard Mr Hampson feared hospitals but was in “10 out of 10” pain on the evening of August 14, 2021, when he sought treatment and care at Dubbo Base Hospital complaining of a “popping” sound in his stomach.
The court heard that at the time, the Kamilaroi-Dunghutti man was suffering from the effects of perforated stomach ulcers, which ultimately killed him.
He was not taken for any scans to investigate his abdominal pain and he was diagnosed by emergency medicine physician Dr Sokol Nushaj as suffering from Cannabinoid Hyperemesis Syndrome (CHS).
The condition is characterised by nausea, vomiting and abdominal pain due to long-term marijuana use.
This is despite, the court heard, Mr Hampson not presenting with vomiting or nausea.
He had smoked cannabis earlier that day.
He was sedated overnight and following 18 hours in hospital, he was discharged.
“There were no further investigations of the ‘popping’ sensation or the cause of the pain such as by giving Dougie an x-ray or a CT scan,” Deputy State Coroner Magistrate Erin Kennedy said in her findings handed down on Tuesday.
He was discharged, given ibuprofen and paracetamol and was told to return to hospital if the pain worsened, despite the nurse who saw him last noting he was holding his stomach and in discomfort.
He died on the morning of August 16 on his friend’s lounge. Despite attempts to revive him, he was pronounced dead at the scene.
Following a two-week inquest in Dubbo earlier this year, the coroner found that the 36-year-old’s death was preventable.
Ms Kennedy found that his symptoms did not justify the diagnosis of CHS.
“Dougie’s death was preventable,” Ms Kennedy said in her findings.
“When revisiting the beautiful reflections by his mother, father, aunt and sisters and brother, and those of the children, it is a reminder that preventable death extends well beyond the person … and what is even more difficult for them to bear is the fact that the loss occurred after he presented to hospital, a place that he did not like to go.”
She said he was discharged “without adequate treatment” and “in pain” and that hospital staff “should have identified the life threatening condition from which he suffered”.
She said that he was not suffering from CHS and he should not have been treated with the sedative droperidol at Dubbo Base Hospital.
She further found that further scans should have been taken and that he should not have been discharged.
“If Mr Hampson had been properly diagnosed, his duodenal ulcers could have been successfully treated,” she said.
“The failure to treat Mr Hampson’s duodenal ulcers led to or contributed to his death.”
She recommended that Dr Nushaj be referred to the Health Care Complaints Commission to investigate whether he engaged in unsatisfactory professional conduct.
She also recommended a raft of institutional changes, including that Western NSW Health consider establishing an indigenous advisory group along with a local Aboriginal health organisation.
Last Friday marked the three-year anniversary of Mr Hampson’s death and outside court on Tuesday his family expressed their anger that his death was preventable.
Mr Hampson’s father, Rick Hampson Snr, said his family had experienced three years of “agony” and “hell”.
“Getting these reforms won’t bring Dougie back, nothing will do that,” Mr Hampson said.
“If we can save the lives of other First Nations people by getting these reforms through, it will go some way to healing the pain my family and I carry inside.”
He said he was “outraged” at the thought of his son dying after being treated for 18 hours and discharged from hospital.
He described his son as a loving parent and uncle, the “joy of the party” and a “one of a kind”.
“Dubbo Base Hospital should have saved our son’s life,” Mr Hampson senior said.