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But 36-year-old Kamilaroi Dunghutti man Ricky Hampson Jr was always afraid of hospitals.
And it was the failings of a regional hospital which ultimately led to his untimely death, a coronial inquest has heard.
Who was Ricky Hampson Jr?
An Aboriginal flag was draped over a table in a courtroom in Dubbo throughout a two-week inquest into Mr Hampson Jr's death by deputy state coroner Erin Kennedy which began on February 26, 2024.
Spread across the table were family photos, eucalyptus leaves, a St George Dragons beer stubby and a glass #1 Dad tankard.
Mr Hampson Jr - known to family and friends as Dougie - was born in 1984 in Camden to parents Ricky Hampson Sr and Lydia Chatfield.
He grew up in Sydney and Canberra and eventually moved to Dubbo with his partner Kellyann Murray. Together they had eight children.
"He was a leader in his family, he was always the one that would get the kids on Christmas time and joke around with them and play games ... he made everybody laugh," Mr Hampson Sr told the Daily Liberal.
However, from his 20s, Mr Hampson Jr struggled with drug use which impacted his mental health and led him to trouble with the law. Between 2017 and 2019 he spent time in and out of prison.
When he was released in late 2020 he committed himself to turning his life around.
"Family is important to me - my family is everything," he told a community corrections officer.
"I am staying clean and I have only been out for three months, everything is finally good."
An unusual diagnosis with "no basis"
But just as things were starting to turn around things took a turn for the worse.
Just after 5pm on August 14, 2021, Mr Hampson Jr visited Dubbo Hospital with a highly elevated heart rate and "10 out of 10" pain after feeling a "popping" and "tearing" sensation in his stomach.
The nurse who triaged him said he was "writhing with pain" in the waiting room. She asked Mr Hampson Jr about the pain and noted what she found in her triage notes.
He was given a triage level two and was taken to an isolation room. It was the height of the COVID-19 pandemic and Mr Hampson Jr had not yet returned a negative test.
Dr Lisa Hu, a young and inexperienced doctor, was assigned to Mr Hampson Jr's care.
She took a brief history, performed an examination of his abdomen and came to an impression of "undifferentiated abdominal pain". She noted what she found, including the popping sensation.
"At the time I wouldn't recognise the significance of that but it was something specific he told me so I thought I should document it," she said.
She spoke to her supervisor, Dr Sokol Nushaj, about Mr Hampson Jr's case. Although he had not examined him himself, he suggested he could be suffering from Cannabinoid Hyperemesis Syndrome (CHS).
CHS is a rare condition that only occurs in daily long-term users of marijuana. It leads to repeated and severe bouts of vomiting, nausea and abdominal pain.
Although Mr Hampson Jr had smoked "a couple of cones" that morning, it was not known to Dr Nushaj when he made the diagnosis. No history of Mr Hampson Jr's cannabis use was taken.
Dr Nushaj said he first considered the diagnosis when he saw Mr Hampson Jr being wheeled into the isolation area of the hospital. He said he got this impression from the way Mr Hampson Jr appeared in his pain, which seemed similar to CHS patients.
Although he said the emergency room had seen a number of aboriginal patients with CHS in the past, he denied that race played a part in the impression
"It was the body pattern, the movement, the agitation that triggered the thought it could be CHS," Dr Nushaj told the court.
"The brain works in weird ways which filters out information which is quite obvious."
Notably, Mr Hampson Jr was not suffering nausea or vomiting. There was no further investigation of the "popping" sensation Mr Hampson Jr reported and he was not given an x-ray or CT scan.
"It is a matter of deep regret," he said.
Dr Nushaj said he did not check the medical notes and that Dr Hu never told him about the "popping" sensation Mr Hampson Jr reported.
But Dr Hu maintains she did inform her supervisor.
"In likelihood I would have remembered that kind of information," Dr Nushaj told the court.
"It's not good news if someone mentions popping or tearing sensation in any part of the body."
Dr Nushaj told Dr Hu that Mr Hampson Jr should be given fluids, reviewed and discharged. But, his symptoms continued so the doctors transferred him to the short stay unit overnight and gave him oxycodone to manage his pain.
At some point during the evening Mr Hampson Jr was also given a drug called droperidol. The drug is used to treat nausea and also acts as a sedative.
The two doctors finished their shift at midnight and Dr Nushaj did a handover with the next doctor, James McBride.
Dr McBride said he was told by Dr Nushaj that Mr Hampson Jr was suffering from CHS. He said he had no reason to question Dr Nushaj's assessment and he did not examine or check up on him through the night.
"It was a busy night from my memory," he said.
"Being in charge of a busy department there were many many other competing priorities ... including patients in the resuscitation bay that needed attention."
Discharged with no wallet, no phone, no ride
The next morning, August 15, Mr Hampson Jr's heart rate was still high and his pain was increasing. But Maree Trow, the nurse attending to him, did not report this to the doctor.
In fact, Mr Hampson Jr was not seen by a doctor at all that morning either.
Nurse Trow said she thought Mr Hampson's pain was caused by constipation he told her he was experiencing, so she gave him some medication to treat it.
He stayed in the hospital until just after midday, when he was discharged. Nurse Trow said Mr Hampson was still in "obvious discomfort" when he walked out of hospital.
"He was holding his lower abdomen and I asked him if he wanted to stay and see if the medication [for constipation] worked... but he said he just wanted to go home," she said.
"I walked him out of the hospital because I was concerned for him."
He was meant to walk into the dreamtime as an aged and frail man, warm in his bed surrounded by his loved ones. Instead he was a young man who died alone in unimaginable pain and suffering.
- Anita Chatfield, Ricky Hampson Jr's sister
She said, in hindsight, she should have been more insistent that he stay.
"I have reflected and I have learned lots from there... It is very sad... we are human and we do make errors of judgement," she told the court.
It is unclear exactly where Mr Hampson Jr went when he walked out of hospital. No-one came to pick him up and he didn't have a wallet or phone on him.
Later that afternoon he arrived back at a relative Marshall Peachey's house by taxi.
He told Mr Peachey that he caught the taxi from a bus stop outside the hospital. It is not known how long Mr Hampson Jr waited at the bus stop before getting in a taxi.
Mr Peachey - who Mr Hampson had been staying with - said he had no idea he had been at hospital. He said he was still in pain when he walked up to the porch and asked him to pay for the taxi.
"He was bending over," he said.
Mr Hampson Jr explained to Mr Peachey that he was walking to a friend's house and felt a "popping" sensation and collapsed on the ground and blacked out. When he came to, he kept walking - it's unclear how he ended up in hospital.
The pair went into the house and entered the living room.
"He kneeled down in front of the lounge, with his knees in front of the lounge and his body and hands on the seat... he said that was the only way it was less painful," Mr Peachey said.
"The only time he moved from the lounge room was so he could go to the toilet."
That was the last place Mr Peachey saw Mr Hampson alive, at around 3:30am on August 16.
At about midday, Mr Peachey's brother asked him if he had checked on Mr Hampson Jr. Mr Peachey went back into the living room and found he wasn't breathing.
He tried to do CPR on Mr Hampson Jr but it was too late. He had been dead for some time.
"I tried to do what I could," Mr Peachey said.
Untimely death 'tore family apart'
Mr Hampson Jr's family had no idea he had been in hospital until they received the news he had died.
Speaking before the coronial inquest on Thursday, March 7, members of Mr Hampson Jr's family said his death tore them apart.
"Losing a son... I can't accept that he's gone. I know he's gone in my mind, but in my heart I have to keep him alive," Ms Chatfield told the court, dabbing her eyes with a tissue.
"I hope that another mother will never, ever have to go through what I'm going through.
"It just breaks me... I don't know what else to say. It took 14 hours for Dougie to come into this world and 19 hours for him to go."
His sister, Anita Chatfield, said "it wasn't just Dougie" who died on August 16. She said his death placed a weight on her shoulders she could never shake.
"He was meant to walk into the dreamtime as an aged and frail man, warm in his bed surrounded by his loved ones.
"Instead, he was a young man who died alone in unimaginable pain and suffering.
When Mr Hampson Jr's body was brought into hospital on August 16 his death was referred to the coroner.
An autopsy was performed and two perforated ulcers were found in his stomach and four litres of fluid was found in his abdominal cavity.
Although serious, it was a condition that could have been treated, an expert told the inquest into his death.
Asked if he thought Mr Hampson Jr would have survived if his ulcers had been detected and treated that night, gastroenterologist Dr Christopher Vickers said there was a "good chance".
"I think his outcome would have been very, very favourable... he would have walked out of hospital," Dr Vickers told the court.
He said the ulcers were likely there for some time before he died and that the sudden pain he was experiencing was likely a result of stomach acid leaking into the abdominal cavity after the ulcers became perforated.
"The pain occurs very quickly," he said.
Inquest revealed 'systemic failures' at hospital
Throughout the course of the inquest, the court heard from medical professionals on shift at the hospital during Mr Hampson Jr's stay, experts in race relations and representatives of the Western NSW Local Health District.
In his closing remarks on Thursday, March 7, counsel assisting the coroner Simmeon Beckett concluded Dr Nushaj's conduct during Mr Hampson Jr's stay may have failed to meet professional standards.
Mr Beckett said Dr Nushaj had made an unfounded diagnosis, failed to properly investigate the systems and did not record check ups or administration of drugs.
When the coroner returns her report, Mr Beckett has recommended she find Mr Hampson Jr could have been treated if he was properly diagnosed, that the care he received at the hospital was not to an adequate standard and that his race likely impacted his treatment.
Not only may it have played a part in the misdiagnosis, many medical professionals were unaware of Mr Hampson Jr's Aboriginality and did not provide culturally-safe care.
Professor Yin Paradies, chair in race relations at Deakin University, told the court this is known as "colour blind racism" where the specific challenges faced by and needs of Indigenous people are not considered.
"Sometimes people think it's good we don't know aboriginality and can provide appropriate medical care on that basis but the evidence doesn't show that," he said.
Ricky Hampson Sr welcomed the expert's evidence. He had been pushing for an inquest for years.
"The medical staff keep saying that if they had known Dougie was Aboriginal, they would have investigated more, reviewed him again, given him better care," Mr Hampson Sr told the Daily Liberal.
"If colour blind racism did play a part in my son's death, we want to know about it. The quality of the medical treatment Aboriginal people receive should be culturally safe.
"We heard evidence that prejudice, including colour blind racism, in this country's healthcare can hurt Aboriginal people, and it needs to be rooted out.
"Dubbo Hospital and the Western NSW Local Health District, in fact the entire health system needs to listen to these experts. Our people need a healthcare system we can trust."
Justice Kennedy is also expected to make a number of recommendations to the Western NSW Local Health District about how they can better help Indigenous patients.
"This process is about using Dougie's experience to assist the Dubbo hospital," she said.
Although some changes have been made since the death, the hospital still has a way to go.
Aboriginal liaison workers are still not available around the clock and in-person training in culturally-safe healthcare hasn't been run since before COVID-19 shutdowns.
Dr McBride, himself Indigenous, told the court there is still a lack of awareness about the fear Indigenous people have about seeking healthcare.
"They have a fear that if they go to hospital they're not going to be taken seriously," he said.
"There is a lack of understanding and awareness of what it means for an aboriginal person to present to hospital, the level of fear that exists in our community and the lack of trust of Indigenous people in our hospital system.
"I dont feel our culture is completely understood by non-Indigenous people, which allows an area where cultural safety isn't at its best," he said.
Deputy state coroner Kennedy is expected to hand down her findings on April 19, 2024.
