The Death Of Ms Dhu Part 4: How Did A Second Doctor Fail To Notice That Ms Dhu Was Dying?

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This is the fourth and final instalment in a series from Michael Brull on the death of Ms Dhu, An Aboriginal woman who died in Port Hedland after being taken into police custody for outstanding fines. Michael’s reporting is based on the recent findings of the coronial Inquest into Ms Dhu’s death, which was handed down last year. You can read part 1 here, part 2 here, and part 3 here.

 

Dr Vafa Naderi’s treatment in short

Doctor Vafa Naderi didn’t give Ms Dhu the same kind of super cursory treatment as Dr Lang. Where Dr Lang’s admittedly “brief” consultation lasted no longer than “several” minutes, Dr Naderi saw Ms Dhu for about 20 minutes. Yet in the end, the results were similar. His medical notes said that Ms Dhu “Presented last night in custody. Complaining of pain. Thought to be behavioural. Again represents still in custody”.

The note says that Ms Dhu “used drugs prior to this”. She was sleeping then “crying in pain all over. Bilteral Chest/shoulders/ribs etc.”

Dr Naderi wrote: “Impression? Withdrawal symptoms? anxiety/personality problems”

He prescribed her the sedative Diazepam, Paracetamol for pain, and sent her on her way. He didn’t take her temperature, and he didn’t X-ray her chest. His discharge diagnosis was “behavioural issues” and “? withdrawal from drugs”.

The coroner’s specialist expert on emergency medicine, Dr Dunjey, explained those “two conditions” that Dr Naderi diagnosed:

“Query withdrawal from drugs is suggesting that a person may be becoming physically unwell because an illicit drug they are using is coming out of their system. Their body is physically craving that drug and it produces a range of symptoms which can include tachycardia, vomiting, diarrhoea, etcetera. So that’s one diagnosis. The second diagnosis is behavioural issues. And I think what – to me what that’s suggesting is, that the doctor has looked at Ms Dhu and felt that she was embellishing her physical symptoms. She was – and plus or minus she is a difficult patient to deal with, because she is cranky.”

That is, Dr Naderi concluded after a 20-minute examination that Ms Dhu was fine, other than withdrawing from drugs, and exaggerating her pain. The pain all over, the moaning, the warm skin, the likely temperature, the high pulse rate – it didn’t register. Ms Dhu was dying from pneumonia and septicaemia, and the doctor put it down to drugs and embellishment.

The coroner observed that “Dr Naderi ended up by agreeing, essentially, with Dr Lang. The overall impression is that neither doctor believed Ms Dhu was genuinely unwell, let alone seriously so. The only reasonable inference was that they thought Ms Dhu’s complaints were exaggerated, or not entirely genuine.”

Dr Naderi agreed that he was influenced by Dr Lang’s diagnosis of “behaviour issues”. He conceded that, “It is hard not to be influenced by what is said before.” Given that Dr Lang’s diagnosis was based on a cursory examination, and influenced by the police claim that Ms Dhu had started faking her pain in response to incarceration, the police contributed, at least to some extent, to Dr Naderi’s ultimate dismissal of Ms Dhu. Yet as we have seen, the coroner’s report explicitly exonerated the police of contributing to Ms Dhu’s death.

Dr Naderi’s finding that Ms Dhu wasn’t genuinely unwell was not the anomalous misdiagnosis of a rookie doctor on his first day at work. Dr Naderi qualified as a doctor in 1993, and had been practicing medicine in rural Western Australia for about 20 years. In that time, he has treated many Aboriginal patients. He started working at HHC in 1999, and became the Director of Clinical Training in 2009. He is not a renegade doctor who made an amateur’s mistake. He is a senior, respected doctor, who has directed the training of doctors in rural medicine for years. Though he gave Ms Dhu more medical attention than Dr Lang, it still took him only 20 minutes to close the book on investigating Ms Dhu’s medical condition.

 

Not seeing the pulse rate on the paper he examined

Our ability to reconstruct Dr Naderi’s assessment of Ms Dhu is hampered by the reliability of his testimony. Whilst not as egregious as the various falsehoods proffered by Dr Lang, they still raise questions about his willingness to come clean with the inquest into Ms Dhu’s death.

For example, there is the issue of Ms Dhu’s pulse. Nurse Hetherington recorded that Ms Dhu had a pulse rate of 126. She didn’t record it electronically, but she wrote it down by hand. Nurse Hall recorded a pulse rate of 113. The coroner observes that the “pulse rate of 126 was handwritten on the presenting complaint, so in the ordinary course, if it was there Dr Naderi would have seen it. He may also be expected to recall it if he did see it.”

Dr Naderi didn’t deny that he saw it. He merely said that he did not recall seeing it, and that if he did see it, it “didn’t make an impression on me”. The coroner responded by accepting Dr Naderi’s submission that “there is insufficient evidence for finding that he saw the handwritten notation by Nurse Hetherington on the emergency department notes when he read them”.

Dr Naderi acknowledged that both 113 and 126 meant tachycardia. He also acknowledged that a pulse rate of 126 is “reasonably high”, and cause for a higher level of suspicion. Yet despite noting that “in the ordinary course”, Dr Naderi would have seen it, and would remember seeing it, the coroner decided to suspend judgment on whether or not he had actually done so.

When asked why he didn’t take Ms Dhu’s temperature, he explained that in “the history provided to me, there was no suggestion of infection. The examination findings were not of infection. There was no trigger otherwise than automatically measuring a temperature to need to do it.” As we have seen, the coroner admonished the nurses for not responding to Ms Dhu’s high pulse rate by taking her temperature. A rate of 113 should have been a good enough trigger for a nurse to take her temperature. A rate of 126 was an even better reason.

The coroner reports that Dr Naderi “agreed that tachycardia was a symptom of infection”. Yet no conclusions are drawn. We are supposed to believe that a senior doctor, with 20 years of experience, who directed clinical training at the hospital, somehow didn’t notice this obvious trigger for taking a temperature. And somehow he didn’t notice the pulse rate on the form he would be expected to have looked at and remembered.

 

The many dubious claims left unchallenged by the coroner

As noted, many of the police and nurses who came into contact with Ms Dhu observed her moaning. Nurse Hetherington wrote in her note that Ms Dhu was “Grunting and moaning”. Dr Naderi claimed that Ms Dhu didn’t “have any grunting or moaning when he saw her”.

The coroner wrote that Dr Naderi “agreed that grunting by a person was a sign of sepsis, but he did not find her to be grunting when he saw her”. She does not analyse this denial, or how plausible it was that Dr Naderi should manage to not hear Ms Dhu grunt in a 20 minute consultation, when it was readily apparent to the triage nurse. Despite moaning throughout the period under review, Dr Naderi blithely claimed not to have noticed any moaning, and the coroner offers no resistance to this extraordinary claim.

The coroner also wrote that Dr Naderi claimed Ms Dhu “showed no signs of respiratory difficulty”. As we have seen, shortly before she left for the HHC, she complained that she was unable to breathe, and the police gave her a paper bag to breathe into.

Ms Dhu also told Nurse Hetherington that she couldn’t breathe. Hetherington was sceptical, writing in her note that Ms Dhu was “talking in full sentances” (sic). Her note also recorded that Ms Dhu had asthma. Despite their lack of medical expertise, as compared to Naderi, somehow they were better able to pick up on Ms Dhu’s breathing difficulties than Dr Naderi.

Ms Dhu admittedly told Dr Naderi that her breath was “catching”. He explained that this meant there was “a pain restricting the depth of her inspiratory movement, rather than not being able to get any air in. He referred to it as a pleuritic pain.” Dr Naderi admitted reading Hetherington’s note about Ms Dhu complaining she couldn’t breathe. None of it counted for Dr Naderi. He still claimed she showed no signs of respiratory difficulty. The coroner doesn’t analyse the plausibility of this denial.

And what about Ms Dhu having “pain all over”? In police custody, she complained, and a note recorded that she was “complaining of all over body pains”. According to the coroner, Nurse Hall found that Ms Dhu had “aches and pains all over her chest, shoulder, abdomen and legs and that it was nowhere specific”. In his handwritten notes, Dr Naderi wrote that Ms Dhu was “in pain all over”. He went on to write “Chest/shoulders/ribs etc”. This mattered, because as he agreed, generalised pain was a symptom of sepsis.

Yet as it turned out, it was merely a really strange coincidence that he used the phrase “pain all over”. He did not agree that she had “all over pain… I know the wording is there, but the way she described it, she had pain in specific areas of the chest, shoulder – left shoulder and then only one left thigh. It wasn’t as generalised. I have written ‘all over’, but my recollection and understanding was that she was talking about specific areas”. Thus, despite the weird coincidence of her various complaints of being in pain all over, that wasn’t really what she meant, and it was just a weird coincidence that he was among those who wrote down that that was what she said.

Unlike the two nurses, Dr Naderi never recorded Ms Dhu’s skin as warm. He was thus able to identify it as normal at the time. Like the nurses, he explained that “he did not consider her to have a fever and she felt well-perfused”. The coroner wrote that had Dr Naderi seen the nurse’s assessment, he would have seen that Ms Dhu’s skin had been described as warm. Except that for him, “warm” meant “there is normal perfusion” and that “the skin felt normal to touch”. By another strange coincidence, which the coroner does not attempt to explain, this explanation from Dr Naderi was “similar to Nurses Hetherington and Hall”.

Luckily for Dr Naderi, this creative interpretation of ticking “warm” instead of “unremarkable” let him off the hook for explaining why he didn’t regard “warm” skin as the kind of symptom worth investigating, say, with a thermometer.

Dr Naderi “ultimately conceded that it would have made sense that if the skin felt normal to touch then the caption marked ‘unremarkable’ should be ticked.” Indeed, Dr Naderi also “conceded that he should have taken Ms Dhu’s temperature, if it had not been taken before it should have been taken by him, and that it was a failure on his part not to take her temperature”. Rather than critically analyse Dr Naderi’s oversight of basic medicine, or attempt to offer an explanation of why it happened, Coroner Fogliani remarkably concluded that, “It is to his credit that Dr Naderi makes these concessions as it demonstrates his insight.”

A highly experienced senior doctor failed to perform a basic medical test that he admitted he should have performed. Whereas another coroner might have discussed whether prejudice played a role in the failure to investigate Ms Dhu’s medical symptoms, this coroner blithely praises him for admitting his fault, and moves on without reflection.

 

Dr Naderi denies and downplays every symptom giving cause for chest X-ray

As we have seen, Ms Dhu likely had a temperature, and her warm skin and tachycardia were signs that her temperature should have been taken. Given that the nurses should have had enough medical knowledge to take Ms Dhu’s temperature, we can surely expect that Dr Naderi would have had that medical knowledge too. Yet there is also the question of the chest X-ray.

To understand this issue, we have to understand whether it would have helped. Dr Dunjey, the coroner’s medical expert, explained:

“it is highly certain that a chest x-ray performed on this visit would be abnormal. The autopsy performed on Ms Dhu after her death, the next day, show bilateral pneumonia, pleural effusions (fluid around the outside of both lungs) and abscess formation. It is just not credible to believe that all of these changes appeared in the 18 hours between her second and third presentations. An abnormal chest x-ray showing disease in her lungs would have forced a reconsideration of the diagnosis given, and would be considered a standard investigation for chest pain.”

That is, if the chest X-ray had been taken, it would have shown that something was seriously wrong with Ms Dhu. She wasn’t faking. So was there good reason for a doctor presented with Ms Dhu’s symptoms to take a chest X-Ray?

Yes. Again, Dr Dunjey observed that “this was a second presentation with the same problem within 24 hours (namely chest pain, being the pain in the rib area). From his experience: “100% of the time we would do a chest x-ray on a patient like this.” That is, this should not have been a difficult call. Furthermore, the coroner found that, “There would have been no difficulty with engaging a radiographer to undertake an X-ray as there was one on call for HHC.”

The coroner concluded: “I am satisfied that Dr Naderi ought to have ordered a chest X-ray and that if taken, it would most likely have been abnormal, and if so, would have changed the course of Ms Dhu’s treatment.”

Yet Dr Naderi testified that he did not see the need to take the chest X-ray. After all, what sign was there of infection? Sure, he conceded that he was aware of her tachycardia. But he denied she had respiratory difficulties (though Ms Dhu told him, Hetherington, and the police she had difficulties breathing). He denied that she was grunting, though the nurse had already observed grunting. The “pain all over” wasn’t pain all over, regardless of what Ms Dhu told him, the police, and a nurse. Thus, Dr Naderi was satisfied with performing an ultrasound. The ultrasound ruled out pneumothorax and haemorrhage in Ms Dhu’s lungs. That was all it took for Dr Naderi to be satisfied that, more or less, there was nothing wrong with Ms Dhu.

Dr Naderi tried defending his conduct, stating that, “I firmly believe if I had done the chest x-ray at the time, it would have not shown pathology.” This was rejected by the coroner.

In the end, Dr Naderi did “ultimately agree that, in hindsight, it would have been better to perform a chest X-ray”. Naturally, the coroner states this is “to his credit”. No analysis is offered of why Dr Naderi failed to perform the chest X-ray, or whether any of his testimony should count against his credit. Again, the coroner doesn’t think to discuss what might cause a highly experienced doctor to ignore obvious symptoms pointing to the need for a medical test. Or why Dr Naderi became the sixth medical professional to decline to perform basic medical tests that would have been normal to expect in the circumstances.

 

From the hospital back to the police: the green light for disbelieving Ms Dhu

At 7:12 pm, Ms Dhu returned. She had been out for over two hours seeking medical treatment. And all she had been prescribed was Panadol. They had already been giving her Panadol in response to her cries of pain. The natural inference for the police was that, once again, she was claiming to be sicker than she was. The hospital had rejected her cries for help twice.

When Ms Dhu got back, First Class Constable George remarked “Paracetamol, Paracetamol? After all that”. He then exclaimed: “Hah!” The coroner accepted that this conveyed to Ms Dhu – and the nearby police – that he believed that she was “feigning (or at the very least exaggerating) her complaints of pain”. Cruel as it was, it was the correct interpretation of how HHC had diagnosed Ms Dhu.

The Fitness to Hold form that HHC gave to the police didn’t have Dr Naderi’s diagnosis on it. But “one of the nurses advised the two police officers” accompanying Ms Dhu at HHC that her “symptoms could be due to withdrawal from drugs. This observation was later relayed to Mr Bond back at the Lock-Up, most likely by Constable Eastman”. Eastman was “fairly sure” she “passed this information on to shift supervisor Mr Bond”. The coroner doesn’t identify which nurse, but it was “one of the nurses at HHC who had attended to Ms Dhu”.

Bond agreed that, “once Ms Dhu had returned from HHC for the second time, he was of the view that she was faking her complaint”. It wasn’t written on the Fitness to Hold form. It simply filtered through word of mouth, from the hospital, to the police, to Bond. As we have seen, the result of this confirmation for Bond was his unshakeable conviction that Ms Dhu was faking. He passed this on to the police who dealt with her on the day she died. It also led to him repeatedly refusing requests on the next day to take Ms Dhu to hospital. Ultimately, Bond himself must be held accountable for his own actions and prejudices. But HHC, too, must be held accountable for contributing to the belief among police that nothing was wrong with Ms Dhu. After all, that was the correct interpretation of how they regarded her complaints.

Whilst we can review the written record from HHC’s treatment of Ms Dhu, we can’t review the verbal conversations between nurses, doctors and police. Undocumented word of mouth was how Dr Lang was convinced that Ms Dhu had been faking her pain symptoms.

In time, that original diagnosis influenced Dr Naderi to also dismiss Ms Dhu’s complaints. And those off the record impressions filtered back to the police, and how they treated Ms Dhu. We may never know exactly what the nurses and doctors said to the police, and vice versa. But we can guess.

Ultimately, those unrecorded conversations helped doom Ms Dhu, compounding the inclination of medical professionals and police to ignore Ms Dhu’s moans.

 

Conclusion

Dr Naderi gave Ms Dhu a sedative at 7:05 pm, five minutes before she left the hospital. The coroner does not explore why the two doctors administered Ms Dhu a single sedative each, without prescribing it on an ongoing basis. Perhaps she was loudly moaning about her pain, pleading for them to take her seriously, and they wanted her to stop bothering them.

Perhaps that’s what it took to get Ms Dhu to give in. She moaned, she groaned, she cried and she screamed, so that the police and medical staff would take her pain and health seriously. She fought and fought, because she was in pain, and she was desperate to live. They refused to listen, and they refused to take her seriously. Perhaps they needed to administer the sedative to make her give in, to destroy any hope that she could make the doctors understand.

Every society has fringe racists, who hold particularly extreme and hateful views about this or that minority group. In this case, there is no suggestion that any of the police or medical professionals involved were neo-Nazis, or otherwise extremist. They were mostly experienced professionals, who regularly dealt with patients and prisoners, some of whom had decades of experience in hand. None of them bore Ms Dhu any particular malice.

And yet, the coroner recorded that one of the police officers “appeared to not be consciously aware that he was dealing with another human being”. Faced with someone totally incapacitated and unable to move, police showed no sense of urgency, casually dragging and then carrying Ms Dhu to their car, and then roughly throwing her into a wheelchair.

It may be said that police are not medical professionals, and simply deferred to the judgment of the hospital that had twice rejected Ms Dhu’s pleas for help. They had no training to determine whether or not Ms Dhu was sick.

But the medical professionals did have that training. And when Ms Dhu showed up extremely sick, they wrote her off. Though not captured in the way police abuse was captured by CCTV, this part of the story may be even more disturbing. How did six medical professionals, with decades of experience between them, all happen to assume that Ms Dhu was faking her pain and symptoms? Why did they all assume Ms Dhu’s moans were solely either being faked or about drugs? Why did none of them take a step as elementary as taking her temperature? Why did neither of the two doctors take an X-ray of Ms Dhu’s chest?

Among the coroner’s failures is that she didn’t meaningfully pursue this question. Dr Lang admitted that her diagnosis was influenced by police claims about Ms Dhu exaggerating her pain. Dr Naderi conceded that Dr Lang’s diagnosis influenced him. Yet the coroner let the police off the hook for making any contribution to the failure to medically investigate Ms Dhu’s condition. Though the testimony of both doctors was marred by several falsehoods, the coroner does not draw any adverse inferences about their testimony, about them, or about their treatment of Ms Dhu.

Whilst the police were relatively candid, and conceded examples of inhumane and unprofessional treatment of Ms Dhu, the medical staff showed no comparable candour. Perhaps we will never know what really happened in HHC on those two days Ms Dhu showed up seeking medical help. What we do know is that Ms Dhu was very sick, and that she moaned, screamed, cried and grunted for help. And the response of the medical staff was to assume she was faking, that it was all somehow related to drugs, and that she wasn’t really sick at all.

The police were caught on camera mistreating Ms Dhu. There is no comparable footage of nurses and doctors engaging in similarly egregious behaviour. Yet that is what happened. It is beyond disappointing that the coroner’s report failed to expose how seriously the medical professionals of HHC failed Ms Dhu.

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Michael Brull

Michael Brull writes twice a week for New Matilda. He has written for a range of other publications, including Overland, Crikey, ABC's Drum, the Guardian and elsewhere. His writings can be followed at his public Facebook page (click on the icon below right).

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