WARNING: This article contains the name and image of an Indigenous person who has died.
A doctor who fatally misdiagnosed a Kamilaroi-Dunghutti man as suffering from complications linked to excessive cannabis use should be referred to the health-care watchdog, a coroner has found.
less than 24 hours after he was discharged from Dubbo Base Hospital in western NSW.
The 36-year-old Kamilaroi Dunghutti man and father of eight was wrongly diagnosed with the drug-related condition cannabinoid hyperemesis syndrome despite lacking key symptoms of nausea and vomiting.
In delivering her inquest findings on Tuesday, Deputy State Coroner Erin Kennedy recommended emergency doctor Sokol Nushaj be referred to the Health Care Complaints Commission for potential unsatisfactory professional conduct.
"Dougie's death was preventable," she told a large group of family members and supporters who turned out to hear the findings.
While Ms Kennedy did not find any specific racial bias, either conscious or unconscious, played a part in Dougie's death, she noted Aboriginality was an important factor to consider in delivering health care.
"No real attention was actually given to Dougie's Aboriginality," the coroner said.
"The concept of colourblind treatment does not work in a section of our community that are prone to far worse outcomes."
Dr Nushaj earlier told the inquest "cognitive bias" led him to misdiagnose Mr Hampson, saying he recognised symptoms of agitation and pain and closed his mind to other alternatives.
Mr Hampson's family welcomed the findings, with father Rick Hampson telling media his son was handed a death sentence by the people who should have saved his life.
"Me and my family are so outraged at the thought of Dougie being surrounded by so many doctors, nurses, medical professionals for 18 hours who had the skills, resources and knowledge to save his life," he said.
"Dubbo Base Hospital should have saved our son's life - instead they killed him."
Dr Nushaj, who was overseeing a busy department at the height of the COVID-19 pandemic, said Mr Hampson's history of cannabis use and blood test results influenced the diagnosis.
As a result of the misdiagnosis, Mr Hampson was administered the sedative droperidol which the inquiry concluded masked his pain and made further diagnosis unreliable.
Among recommendations made by the inquiry were that the Western NSW Local Health District consider establishing a standing Indigenous consultation and advisory group.
It was also recommended NSW Health consider whether it should amend its practices to ensure all medical and nursing clinicians are advised of the Aboriginal or Torres Strait Islander status of patients.
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