This is the second in a three part series by Michael Brull probing the coroner’s report into the death of Ms Dhu, a young Aboriginal woman held in police custody for unpaid fines, who died in agony in her cell a few days later. Part 1 of this series can be read here.
“The evidence does not establish that the police caused or contributed to Ms Dhu’s death.”
– Inquest into the Death of Ms Dhu
One of the most unfortunate failures of Coroner Rosalinda Fogliani’s report on the death of Ms Dhu is its exoneration of the police for Ms Dhu’s death. Another major weakness is its weak and inadequate scrutiny of the medical professionals who treated Ms Dhu.
In a way, these weaknesses are linked. Ms Dhu was failed by the nurses and doctors who were quick to assume she was okay, that she was faking her symptoms, and that they didn’t need to do the most basic tests. Yet for the most part, the coroner’s report lets them off the hook.
Fogliani also fails to discuss the interplay between police and medical staff. When the police took Ms Dhu to the hospital, hospital staff treated her with suspicion. When they claimed Ms Dhu only claimed to be in pain when she was told she would be in custody for a while, the medical staff were influenced. They then confirmed the hunch of the police officers, who spread the word around that Ms Dhu wasn’t really sick, and was just withdrawing from drugs.
Police responsible for Ms Dhu accordingly assumed that she wasn’t sick, and her complaints could be ignored.
When the police brought Ms Dhu back the next day, once again the nurses were quick to assume Ms Dhu, accompanied by police, wasn’t so sick. The negligent response of the nurses to Ms Dhu, along with the previous diagnosis, influenced the second doctor to reach similar conclusions to the first.
Armed with the confidence of two hospitals turning Ms Dhu away, the police were now armed with unshakeable certainty. Ms Dhu was a withdrawing drug addict, and all of her moans were just a ruse.
The nurse who mocked Ms Dhu’s pain
About four hours after being taken into police custody, Ms Dhu arrived at Hedland Health Campus (HHC) at 9:19pm according to CCTV. She was quickly seen by the triage nurse, Glenda Lyndsay. Fogliani wrote that Lyndsay testified “the male police officer (who was Constable Shaw) had told her that when Ms Dhu was told she was going to stay overnight in the cells she started complaining of pain and asked to come to hospital”.
In fact, Ms Dhu had informed police at the first instance of a broken toe, a foot blister, and a broken rib. CCTV footage showed her walking with “difficulty”, favouring her right side as soon as she got out of the police vehicle.
This first impression proved indelible. Though Ms Dhu was groaning in pain, Lyndsay wrote down her pain score out of 10 as only 3. There is video footage from earlier that day of Ms Dhu. She tells Constable Carrie Sharple, in anguish, that, “I’ve been in pain all day!”
When Sharple asked her to rate her pain, Ms Dhu said 10. That was less than half an hour before Nurse Lyndsay wrote down Ms Dhu’s pain score as 3. The coroner does not attempt to explain this discrepancy – especially in light of the fact that virtually every single other person to interact with Ms Dhu over the next two days thought she was exaggerating her pain.
Informed by the police that the pain was suspicious, Lyndsay gave Ms Dhu a triage score of 4. 1 is for the most urgent cases, 5 is for the least. The score of 4 indicated that Ms Dhu’s case was not so serious.
After seeing the triage nurse, Ms Dhu saw the treating nurse, Samantha Dunn. First Class Constable Buck testified that when Nurse Dunn touched Ms Dhu’s shirt, Ms Dhu recoiled and said “ow”. “The nurse responded with words to the effect of “I didn’t touch you” or “I hardly touched you” and as the nurse turned her head away from Ms Dhu she rolled her eyes. Constable Shaw had a similar recollection and inferred that Ms Dhu may be exaggerating her pain.”
The two police officers got a clear message from the medical staff. Ms Dhu’s condition was not so serious. When she complained of pain, it wasn’t credible. And the medical staff got a similar message from the police. Ms Dhu’s complaints of pain should be treated with suspicion. Her pain had magically gotten worse when she was told she would stay overnight in custody. Each reinforced the prejudice of the other.
This dynamic is demonstrated in the coroner’s report, but not explained or analysed. No attempt is made to account for the prejudice of the medical staff. How could they be so sure that Ms Dhu’s pain shouldn’t be investigated, when it was their job to do so? The coroner’s report doesn’t make any effort to pursue this question.
Doctor Lang’s veracity
Anne Lang qualified as a doctor in 2001, and had been working in emergency medicine for about 10 years when she saw Ms Dhu.
It is hard to know what happened in her consultation with Ms Dhu, because it seems virtually none of her claims can be treated as reliable. The coroner doesn’t directly accuse Dr Lang of lying, or even of dishonesty. Yet Fogliani repeatedly rejects Dr Lang’s claims.
For example, there is the issue of the length of Dr Lang’s consultation with Ms Dhu. Comparing CCTV times to hospital records, “it became apparent that there was a discrepancy in the hospital notes that potentially reflected upon Dr Lang having spent a shorter than indicated time examining Ms Dhu.”
The CCTV showed that Ms Dhu arrived at 9:19pm, and left 20 minutes later at 9:39. In those 20 minutes, Ms Dhu was assessed by the triage nurse, the treating nurse, and Dr Lang, and then discharged.
Strangely, “On her medical notes, Dr Lang appears to have initially recorded that Ms Dhu left the emergency department at 21:30, then crossed it out and wrote 21:45. However, the CCTV at the Lock-Up recorded that by 9.43 pm Ms Dhu had returned.” The coroner did not explore the discrepancy in times, or when Dr Lang amended her records.
Dr Lang denied “that she only spent several minutes with Ms Dhu,” but “the evidence of recorded times establishes that that was indeed the approximate length of Dr Lang’s examination of Ms Dhu. Dr Lang herself accepted that her examination of Ms Dhu was ‘brief’.” In fact, the coroner’s report says (paragraph 75) that Dr Lang reviewed Ms Dhu at 9:36.
It is possible that this relies on the inaccurate hospital records. If the time is accurate, however, then Dr Lang examined Ms Dhu for around three minutes.
Or take another claim of Dr Lang. Dr Lang testified that she found Ms Dhu “to be angry, very agitated, quite loud and a little bit disruptive to the emergency department.” The coroner observed that, “Neither the triage nurse (Nurse Lindsay) nor the treating nurse (Nurse Dunn) experienced Ms Dhu to have been disruptive, emotional or angry on 2 August 2014.
Constable Shaw and First Class Constable Buck gave evidence to similar effect, with First Class Constable Buck stating that she was compliant and not aggressive.” Furthermore, “The CCTV captured images of Ms Dhu walking into and out of the HHC, shortly before and after Dr Lang saw her. Those images show a young woman walking slowly, hunched over, and with a serious and subdued demeanour. There is no indication whatsoever of an aggressive stance or attitude on the part of Ms Dhu on the CCTV.”
Under cross-examination, Dr Lang “accepted that her recollection of Ms Dhu being disruptive may be false and that her description of Ms Dhu as being verbally aggressive was an exaggeration.”
However, these claims served to justify her reliance on police. Dr Lang claimed that as she found it difficult to get a history from Ms Dhu, she asked the police. What they told her was recorded in her notes: “Taken into police custody this evening. Pain free initially. When informed she would have to spend the night in police detention, she became inconsolable, complaining of acute… rib pain.” Dr Lang recorded that Ms Dhu was hyperventilating, and gave her a sedative (“for agitation”) and Endone, a very strong pain killer, before the consultation was over.
The police were reluctant to point fingers at each other as to who had told Dr Lang that Ms Dhu had originally been pain free. But Dr Lang said that claim came from the female police officer – Buck.
Buck said she remembered hearing another police officer tell her about Ms Dhu’s originally non-existent pain back at the police station. Buck claimed not to remember who had told her that, and her colleague Shaw claimed not to remember either. However, their superior officer, Sergeant Patchett, admitted to investigators that this was his view at the time.
Despite the litany of untrue and unreliable statements by Dr Lang, the coroner makes no observations about how honest Dr Lang was, or about her willingness to level with the inquest. The coroner does not question whether the unreliability of Dr Lang in statements where the truth could be verified should be weighed against the truth of her other claims, where there was no independent way to test Dr Lang’s claims.
For example, Dr Lang testified that Ms Dhu “denied any current respiratory symptoms and further denied any symptoms consistent with acute infection including fever, rigors, sweats, lethargy or malaise. Dr Lang conceded that there should have been a record in her handwritten notes in Ms Dhu’s hospital file that there were no respiratory or acute infection symptoms”.
We are simply expected to take on trust that she checked for all of those things in her “brief” consultation. Her note at the time claimed there was “no evidence of acute pathology”. She later said that she found “no detectable problem in [Ms Dhu’s] chest”.
That is, it is possible that Dr Lang checked for every relevant thing in the brief consult, and forgot to write them down. It is also possible she didn’t check for those things, and quickly wrote off Ms Dhu, on the basis of the false claims and prejudices of the police and nurses against Ms Dhu.
The coroner doesn’t pursue that line of thought, content with one expert saying it was theoretically possible to conduct an adequate analysis in the limited time that Dr Lang allocated to Ms Dhu.
She did not believe Ms Dhu had a broken rib
For the most part, the coroner does not criticise Dr Lang for the truthfulness of her testimony, nor does she criticise the medical care provided. She says “there is no deficiency in the medical treatment provided by Dr Lang to Ms Dhu on 2 August 2014”, except for “the recording of the discharge diagnosis as ‘behaviour issues’”.
That is, despite confronting an admittedly distressed patient, who half an hour earlier could be heard crying and moaning, saying she was in pain “all day”, who was allegedly hyperventilating, and super-sensitive to the touch of the treating nurse, Dr Lang didn’t think she was actually unwell.
According to the coroner, “Dr Lang’s evidence was that she did not believe Ms Dhu had a broken rib. She formed the view that Ms Dhu was seeking to exaggerate her movements in order to be provided with pain relief”. Her hospital note diagnosed Ms Dhu with “behavioural gain”.
One of the coroner’s medical consults explained that the diagnosis is “suggesting that Ms Dhu was cranky and was behaving in a certain way to generate a response, perhaps to get medication of some kind. But what it’s saying is – it’s suggesting there is not a physical cause for her illness and it’s misbehaviour.” That is, it means, “I don’t think this person is sick. I think they are behaving in a certain fashion to achieve some other goal.”
When asked what the gain was, Dr Lang replied: “I think to gain my attention, to gain pain relief, to gain a reaction… possibly she was acting out a little bit”.
Dr Lang later claimed that she had not committed to this diagnosis. She actually had a secret diagnosis, which she didn’t record anywhere, or mention in her witness statement, that Ms Dhu had “musculoskeletal” pain.
In the “discharge diagnosis”, Dr Lang wrote “behaviour issues”.
Consider the amount of care Dr Lang provided. She dismissed Ms Dhu as completely well, within several minutes at most, without wondering if it was worth investigating if there was a medical cause for Ms Dhu’s readily apparent emotional and physical distress.
Yet despite diagnosing her behaviour as drug seeking, she still provided Ms Dhu with Endone, a very strong medication. If she wasn’t sure if Ms Dhu was sick, why not take the time to conduct further tests? And if she was so sure there was nothing wrong, why prescribe such strong pain relief?
There is another point worth considering. Dr Lang administered a dose of Endone to Ms Dhu. But there is no record of any of the police giving Ms Dhu any Endone. Indeed, several of them gave her Panadol.
The coroner doesn’t pursue this line of inquiry, but it appears that Dr Lang simply gave a single dose of Endone, and Diazepam (a sedative) to Ms Dhu, without any intention that those medications be taken on an ongoing basis. That is, Dr Lang gave Ms Dhu a single dose of a strong pain killer, and a sedative, just whilst she was in the hospital, loudly moaning. And then that was it. It appears Dr Lang’s concern was simply to pacify her loud patient, until Ms Dhu was taken away.
The coroner doesn’t even discuss why Dr Lang appears to have given Ms Dhu a single dose of those medications. However, Fogliani does criticise Dr Lang for her diagnosis, arguing that it could “contribute to premature diagnostic closure.”
This is indeed what happened. Fogliani says that Dr Lang spent an “insufficient amount of time assessing Ms Dhu”, but does not criticise her for premature diagnostic closure. And it does not criticise the police or their contribution to Dr Lang’s premature diagnostic closure, though it is hard to avoid the conclusion that her brief examination of Ms Dhu, and diagnosis of “behavioural gain”, was strongly influenced by them.
Shaw returned to the police station, and briefed the others on “his observations and inferences”. Naturally, they picked up on the doubts of the doctor and nurses, who hadn’t shown any signs of taking Ms Dhu seriously.
From the rushed medical consultation, to the low triage, to the nurse rolling her eyes at Ms Dhu recoiling in pain, and the discharge diagnosis, the clear message was that Ms Dhu’s moans were totally out of proportion to her actual level of sickness. The police gave the medical staff a green light to ignore Ms Dhu’s groans, and they received their first green light in return. And the coroner purported not to notice those green lights.
* Part 3 of this feature will be published tomorrow, February 8.