This is the third in a four 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. Part 2 can be read here.
On 3 August, her second day in custody, Ms Dhu repeatedly complained about her pain. When she walked, she was hunched over. She pressed the button for guard attention four times from 1:17pm to 1:47 pm until finally she was given some water and Panadol.
She pushed the button five more times from 3:44. Sergeant Rick Bond’s notes said she was “complaining of all over body pains”. At 4:30pm, she complained that she found it difficult to breathe. First Class Constable George gave her a paper bag to help with her breathing. George told Bond, who decided she would once again be taken to the local hospital, Hedland Health Campus (HHC), only 200 metres from the police station.
Ms Dhu was very sick: the signs were there if they’d looked
Ms Dhu arrived at HHC at 4:59, and immediately saw the triage nurse, Alyce Hetherington. We can’t be sure of her medical state at that point, due to the failure of medical staff that day to perform basic observations on Ms Dhu. However, with the assistance of medical experts, the coroner Rosalinda Fogliani reconstructed Ms Dhu’s physical state on her second visit to hospital.
The coroner was “satisfied that some of Ms Dhu’s features upon presentation on 3 August 2014 (taking account of her presentation the day before) would have been clues to an underlying infection, namely her rapid pulse, warm skin, difficulty breathing, her history of a broken rib, her complaints of rib pain, developing into complaints of all over body pain, on a background of a history of intravenous drug usage”.
That is, there were numerous signs that Ms Dhu was unwell, when she presented in hospital on 3 August. If those signs – the warm skin, rapid pulse, difficulty breathing and so on – were taken seriously, and investigated, the medical team may have found out Ms Dhu’s condition, and saved her life. However, they failed to do so.
The coroner explained that Ms Dhu “displayed symptoms of infection on this date. Unfortunately, as her temperature was not taken, I cannot now say for certain whether she was febrile, but I consider it highly likely that she was febrile. Whilst a chest X-ray was not taken, I consider it highly likely that she had developed pneumonia by this stage”.
If they had run those tests, they could have diagnosed Ms Dhu’s condition, and treated her for it. As Fogliani wrote, “Ms Dhu’s death could potentially have been prevented on 3 August 2014.” By that stage, “antibiotics would not have been as effective as they would have been the day before”. Yet as we have seen, Dr Lang needed no more than several minutes to decide that there was nothing physically wrong with Ms Dhu.
If one of the two nurses had taken Ms Dhu’s temperature, she might be alive. Here, we will turn to why that didn’t happen.
Ms Dhu probably couldn’t give a number between 1 and 10: Triage Nurse Alyce Hetherington
Triage Nurse Alyce Hetherington was a Registered Nurse, who graduated in 2006, and qualified as a triage nurse in 2011. Whilst not as experienced as some of the other medical staff who saw Ms Dhu, she was by no means an amateur. Eight years of nursing experience, and three years in triage nursing, should surely be enough for Hetherington to be familiar with the basics of nursing.
Among those basics would be the expectation that Hetherington would take Ms Dhu’s temperature, irrespective of her symptoms. Nurse Jones, a Registered Nurse for 32 years, who rushed to save Ms Dhu on 4 August, told the coroner that “it is desirable to do a temperature during a triage assessment and we are expected to do that at Hedland Health Campus”. Nurse Lyndsay, a Registered Nurse with 36 years of experience, saw Ms Dhu on 2 August. Her testimony was that she “was taught to take a full set of observations from a patient at the triage stage, which included temperature”. According to the coroner, Lyndsay explained that taking a temperature was what was “normally expected”.
When Hetherington saw Ms Dhu, she wrote down that Dhu was “moaning++ Multiple complaints”. Also, Dhu’s “Rib cage is sore – pt states that because she has been sleeping uncomfortably it had gotten worse… Grunting and moaning.” Disturbingly, First Class Constable Vicki Eastman – one of the original arresting officers – testified that Ms Dhu was breathing heavily. Hetherington recorded that Ms Dhu’s breathing was “unremarkable”. The coroner does not attempt to square or explain this inconsistency.
Hetherington didn’t record a pain score from Ms Dhu. That is, she didn’t ask Ms Dhu what her pain was on a scale from 1-10. Hetherington said she couldn’t remember if she had, but “if she did ask, it was likely Ms Dhu was unable to give her a numerical answer that she could record”.
The coroner commented that “I can see no basis for Ms Dhu having lacked capacity in this regard, and I reject the suggestion”. It is perhaps indicative of what the coroner refers to as “preconceptions”, that Hetherington could gratuitously suggest that Ms Dhu was incapable of providing a number between one and 10. As seen, when Sharples put this daunting challenge to Ms Dhu the day before, Ms Dhu’s answer was 10.
The coroner didn’t pursue why Hetherington didn’t think Ms Dhu was capable of giving a numerical answer between 1 and 10. The coroner also didn’t put the question as to whether Hetherington’s views about Ms Dhu’s mental faculties might have played a role in her failure to take Ms Dhu’s temperature.
Though the assessment was brief, Hetherington was quickly convinced that Ms Dhu’s condition was not quite genuine. She thought Ms Dhu’s moaning and grunting was “voluntary”. Hetherington claimed that, “She was able to stop moaning and grunting to speak and also to drink”.
Hetherington took Ms Dhu’s pulse, and wrote by hand that it was 126 beats per minute. A rate over 100 is considered abnormal, and is referred to as tachycardia. As seen, it was one of the signs of infection the medical staff should have picked up on. This was one of the signs that Ms Dhu’s temperature should have been taken.
Hetherington herself was aware that a fever can cause tachycardia. Instead, she formed the view that “Ms Dhu was tachycardic due to dehydration, recent drug use and agitation.”
Hetherington also ticked that Ms Dhu’s skin was warm. This was another sign that Ms Dhu was “febrile”. That is, that she had a fever. Even those of us without medical training are familiar with the practice of taking someone’s temperature if they seem to be sick. Hetherington was presented with a clear sign that Ms Dhu had a fever. If she knew Ms Dhu’s skin was warm, why didn’t she take her temperature?
Hetherington explained that “warm” meant that Ms Dhu’s skin was actually just “normal”. The coroner asked why Hetherington didn’t just tick the seemingly more appropriate box, “Unremarkable”. Hetherington replied that, “I don’t think anyone’s circulation can be unremarkable. If you touch someone’s skin it’s going to be warm or cool.” Hetherington went on to submit that, “Warm is what you would expect when you touch a healthy person. It means that they’re well perfused.”
Like most people, I had not heard that term before. The coroner remarked that “This is the first occasion upon which the expression ‘well perfused’ was substantively used by a witness, and it became a feature of the evidence given by some of the subsequent witnesses.” That is, as we will see, at a certain point in the inquest, other witnesses also started adopting the term “well perfused”, to explain their own failures to take Ms Dhu’s temperature.
Regardless, the coroner dismissed this argument. Fogliani called it “self-evident that the emergency department form contemplated ‘Unremarkable’ to be selected where the skin temperature was considered to be normal.” The “implication” of ticking “warm” was that “there had been a clear indication to Nurse Hetherington at that point in time that Ms Dhu’s temperature ought to be taken.”
Thus, Hetherington “did not take Ms Dhu’s temperature, did not complete the ‘pain score’ section in Ms Dhu’s emergency department notes, did not record whether Ms Dhu was re-presenting with similar or same symptoms within 48 hours and gave Ms Dhu a triage score of 4. This was the second lowest priority score and placed her at low acuity.”
The coroner concluded that the appropriate triage score should have been 2, “or at the very least, of 3”. This mattered, because “a low score can be a source of clinical bias”. That Hetherington “miscalculated” Ms Dhu’s triage score “had the real potential to contribute to premature diagnostic closure.” As medical expert Dr Stephen Dunjey testified,
“When a patient gets a 4, they sit in the waiting room, they are supposed to be seen within an hour. It is often much longer than that. It could be two or three hours before they are seen but it is clear that one of your colleagues has made an assessment that says, ‘this patient is not particularly sick’, and it can’t help but change the way you approach the patient and we talked about the way it can be difficult to cast the shackles off.”
Ms Dhu’s low triage score meant that she had to wait about 105 minutes – close to two hours – before she could see the treating nurse.
Why was she so dismissive of Ms Dhu’s complaints? We may never know what happened within Hetherington’s mind and heart. We can know that she was presented with an Aboriginal woman, who admitted to using drugs, and who was in police custody.
We also know that even at the inquest, when she had the opportunity to present her actions in the most sympathetic light, she thought it might be a reasonable defence to suggest that Ms Dhu was incapable of stating a number between one and 10.
From a cursory medical examination, Hetherington evidently formed a very dim view of Ms Dhu’s mental capacity, and also her honesty. Hetherington was so confident of the latter she didn’t think it worthwhile to take Ms Dhu’s temperature, just in case her moans were actually genuine. Hetherington seems an example of what the coroner identified as part of a societal pattern of “assumptions being formed in relation to Aboriginal persons”.
You can usually feel a temperature with your hand: Treating Nurse Gitte Hall
Treating Nurse Gitte Hall was enrolled as a nurse in 1983, and started training to become a Registered Nurse in 2013. With over 30 years of experience, and 10 years in emergency departments, her oversights were not due to inexperience or professional incompetence.
Ms Dhu “complained to Nurse Hall that she had aches and pains all over her chest, shoulder, abdomen and legs and that it was nowhere specific”. Hall, too, didn’t take Ms Dhu’s temperature. She said that there were “only… two thermometers in the emergency department and they were ‘quite hard to get quite often.’” It is possible that this is true. However, the coroner takes Hall’s claim at her word, without showing any sign of having investigated whether that claim was correct.
Hall claimed she didn’t look at the triage form, and so she supposedly started the process from scratch. She found that Ms Dhu’s pulse rate was now 113. The coroner suggests it fell from 126 because during the extended wait, the police kept her in an air-conditioned vehicle.
Like Hetherington, Hall didn’t take Ms Dhu’s temperature, and also didn’t take her pain score. She also found that Ms Dhu’s skin was warm. And like Hetherington, she solemnly explained to the coroner that warm skin didn’t mean warm skin. It actually meant that Ms Dhu “felt normal – like, normal body temperature. You can usually feel with your hand.” There wasn’t much point to using a thermometer, as it would “just confirm, basically, the numbers that you need to make it accurate, basically.”
Hall went on to claim that Ms Dhu’s “warm” skin actually meant that she was “well perfused”. The coroner does not analyse the strange coincidence that Hall and Hetherington should use the same technical term in response to their shared failure to take Ms Dhu’s temperature when they felt her warm skin.
The coroner notes that “as Nurse Hall had identified Ms Dhu to be tachycardic, she ought to have taken her temperature. It also ought to have prompted Nurse Hall to at least check whether Ms Dhu’s temperature had been taken at triage. As Ms Dhu’s temperature had not been taken at triage that responsibility fell to Nurse Hall”.
Hall “attributed the higher pulse rate to Ms Dhu’s agitation, noting that she observed her to be ‘quite anxious and emotional’”. She concluded that Ms Dhu’s complaints “coincided with the story that she was withdrawing from drug use”.
Like Hetherington, she didn’t need to run any tests, or perform basic observations. Why bother seeing if there was a medical cause for Ms Dhu’s pulse rate and warm skin? She knew that Ms Dhu wasn’t really sick. She used drugs, was in police custody, and was Aboriginal. Once again, it turned out that that was all that mattered. After one doctor and three previous nurses had rejected Ms Dhu’s cries for help, Hall became the fourth nurse to assume that nothing was wrong.
At the time, Ms Dhu was “in the process of dying from septicaemia and pneumonia”. Four nurses assumed she was exaggerating, and was actually withdrawing from drug use. In that one day, when there were readily observable symptoms indicating that Ms Dhu had a temperature, two nurses were so sure she was fine they didn’t even both looking for a thermometer.
The result was that when Dr Vafa Naderi finally saw Ms Dhu, he was not presented with the obvious evidence of Ms Dhu’s infection.
And so Ms Dhu died.