An Aboriginal teenager who died in prison from complications due to rheumatic heart disease would not have died if he had seen a specialist, a Western Australian coroner has found.

The 19-year-old Miriuwung and Gajerrong man, referred to by the court at his family’s request as Mr Yeeda, died in May 2018 at the West Kimberley regional prison after suffering severe aortic regurgitation stemming from his condition.

WA coroner Ros Fogliani said there were missed opportunities to ensure Mr Yeeda received appropriate medical care, including a failure to follow up on a request for an appointment with a specialist cardiologist. Fogliani wrote that if the teenager had undergone aortic valve replacement surgery, “it is likely that his death would have been prevented”.

This is another case of an Aboriginal death due to systemic neglect.  Sarah Collard reports numerous missed opportunities for appropriate referral and health care interventions here.