By DAN RYAN
Cultural safety and greater access to health services have been highlighted as crucial needs for Cowra residents, following a coronial inquest into the death of Wilfred “Whippy” Robert Williams.
In a 46 page report, the state’s Deputy Coroner, Harriet Grahame, found that on September 13, 2019, the 45-year-old died of Diabetic Ketoacidosis with multi-organ failure caused by pneumonia.
Deputy Coroner Grahame made three recommendations in delivering her report into the death of Whippy. They included calling on the health district to examine developing an Aboriginal Health Partnership Advisory Consultative Group, to review the efficacy of the cultural competency training for medical staff, and to provide patients with access to an Aboriginal Health Worker 24 hours a day, wherever possible.
The Deputy Coroner found that ultimately, Whippy’s death was preventable, after nursing staff missed key moments to provide potentially life-saving care. Mistakes included not notifying the medical officer [doctor] working at Cowra Hospital the night Whippy presented with an elevated heart rate, nor formally identifying his Aboriginality or pre-existing health conditions.
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In her report, Deputy Coroner Grahame laid plain the need for expanded healthcare access at every level in Cowra, from finding an appointment with a GP to emergency care at the Cowra Hospital.
“The Court heard evidence that the Cowra community is very under-resourced in terms of health care and related outcomes. As such, we must continue to push for more Aboriginal Health Workers to be trained,” she said in her report.
“In my view, there remains work to be done within the [Western NSW Local Health District] to strengthen cultural safety by implementing some kind of Aboriginal Health Partnership Advisory Consultative Group.”
The Deputy Coroner noted the ‘enormous pain and anguish’ caused in the community by Whippy’s death, which significantly impacted the trust residents had in the local healthcare system.
“I have come to the conclusion that flaws in the triage process resulted in lost opportunities which ultimately robbed Whippy of any chance of survival. Whippy’s condition was treatable and his death likely preventable with appropriate and timely medical care,” Deputy Coroner Grahame wrote in her findings.
“A new hospital will be opened shortly. I hope the [Local Health District] finds ways to rebuild trust with those affected by Whippy’s death.”
The Deputy Coroner’s report can be read in full at: www.coroners.nsw.gov.au/documents/findings/2025/Inquest_into_the_death_of_Wilfred_Whippy_Williams.pdf
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