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Inquest reveals how health and justice systems failed sick Kununurra teen Seth Yeeda in need of heart surgery

An inquest has uncovered damning evidence of how a Kununurra teenager who required urgent heart surgery was failed multiple times by the WA justice and health systems. Miriuwung Gajerrong teenager Seth Yeeda died in custody at Derby’s West Kimberley Regional Prison, pictured, on May 3, 2018, just six weeks before his scheduled release. Since then, his mother Marlene Carlton has led the charge to find answers as to how her 19-year-old son died, including why he was denied the opportunity to receive heart surgery that could have saved his life. Last week, she finally received some answers through testimonies from witnesses about the circumstances of his death at a coronial inquest in Perth. “Disease of poverty” Mr Yeeda suffered from rheumatic heart disease; a condition caused by a streptococcus A infection that can develop into rheumatic fever and cause permanent damage to the heart valves. Professor David Celermajer, who gave expert evidence at the inquest, described the condition as a “disease of poverty” that was “almost wiped out” in non-Indigenous communities in Australia. Medical records presented at the inquest showed Mr Yeeda first underwent surgery to repair damage to an aortic valve caused by the disease at the age of nine. Although the teenager was prescribed monthly injections to prevent further heart deterioration, Dr Celermajer said Mr Yeeda had a “horrendously leaky valve” that urgently required another surgical replacement. Cancelled surgeries Mr Yeeda was booked in twice for surgery to replace his damaged heart valve, but neither appointment went ahead. While the inquest heard from doctors who believed the first booking — planned for March 2015 — was cancelled by Mr Yeeda, it is understood a second attempt at surgery in March 2016 was postponed by medical staff at Princess Margaret Hospital after Mr Yeeda was imprisoned in January 2016. The court was told staff at PMH put the surgery “on hold” as they awaited the outcome of the teenager’s scheduled court hearing in February 2016. The surgery was never rescheduled. Dr Celermajer said the procedure, which was “readily available to almost every other Australian” would have had a high probability of preventing Mr Yeeda’s death. Taking into consideration the three-year delay from his initial surgery booking, Dr Celermajer said there would have been significant urgency for Mr Yeeda to receive the potentially life-saving treatment. Referrals “fall through the cracks” After spending time in Albany Regional Prison, Mr Yeeda was transferred to West Kimberley Regional Prison in December 2017. There, he returned abnormal results from an electrocardiogram and was given a referral to see the WA Country Health Service’s cardiology provider, WA Cardiology, for an updated assessment on his condition. The referral was marked as urgent for completion within 30 days. However, unbeknown to WKRP doctor Rodger Todd, WA Cardiology’s contract with WACHS was due to end by December 31, with Perth Cardiovascular Institute named the new provider. WA Cardiology’s Dr Chris Judkins took the stand at the inquiry, stating that while WACHS had requested relevant medical information of patients, WA Cardiology was “not compelled” to provide it due to privacy and commercial concerns. He conceded WA Cardiology did not respond to PCI’s attempts to discuss handover logistics. As a result of poor communication between the three parties, the inquest heard several referrals fell through the cracks, preventing patients from being rebooked for cardiology appointments. “Communication could have been much better,” Dr Judkins said. Dr Todd criticised WACHS for poor communication on its decision to change providers, saying the organisation should have informed WKRP in the months before the intended change. “It is not sufficient,” he said. Missing referral It wasn’t until almost two months later that Dr Todd was alerted of the change in provider and again referred Mr Yeeda to see a PCI cardiologist at Derby Hospital. However only an incomplete, unsigned copy of the referral from WKRP was presented to the court. There is no record of the referral ever being received by Derby Hospital or PCI, and Mr Yeeda never saw a cardiologist again. Dr Joy Rowland, from the Department of Justice, who was involved in a review of Mr Yeeda’s death, said despite attempts to rectify the first failed referral by the prison’s medical team and Dr Todd, the second referral appeared to have been lost. This resulted in Mr Yeeda never seeing a cardiologist during his time at WKRP, despite his urgent December referral and initial surgery booking in 2015. “Accidents do happen,” she said. “It went under the radar that he hadn’t yet been seen by a cardiologist.” Dr Todd said he did not follow-up to see if Mr Yeeda’s referral had gone ahead, and his next appointment with the teenager was not for another six months. Lift in exercise ban Dr Todd said he advised Mr Yeeda against participating in physical activity to prevent further stress on his heart as he awaited a cardiology appointment. The Miriuwung Gajerrong man was marked as unfit for work and sport from May 2017 in a prison alert system. However, the inquest was told a nurse at WKRP changed his status less than a month before his death, allowing him to work and participate in sport without alerting officers of his heart condition. The nurse could not recall why she changed the alert and had no recollection if she sought advice from a doctor before changing Mr Yeeda’s status within the system. Death On May 3, 2018, Mr Yeeda lost consciousness at WKRP. It took 11 minutes for him to be found and for WKRP staff to begin CPR. Attempts to revive Mr Yeeda were unsuccessful, and his official cause of death was listed as acute rheumatic heart disease. He was just six weeks from completing his prison term. The inquest into his death ended on September 2. No date has been set for Coroner Rosalinda Fogliani to hand down her findings.

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Inquest reveals how health and justice systems failed sick Kununurra teen Seth Yeeda in need of heart surgery

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Inquest reveals how health and justice systems failed sick Kununurra teen Seth Yeeda in need of heart surgery