Coroner recommends investigation into death of intellectually disabled Aboriginal woman at Sydney hospital

A doctor who questioned the merit of resuscitating a young, intellectually disabled Aboriginal woman who died in a Sydney emergency department should be investigated by health authorities, a coroner says.

Shona Hookey, 29, died at Campbelltown Hospital on July 19, 2013 as a result of peritonitis caused by a twisted bowel, which was not diagnosed until an autopsy was conducted.

NSW Deputy State Coroner Hugh Dillon today handed down inquest findings, saying he would refer allegations a doctor may have discriminated against Ms Hookey due to her intellectual disability to the Health Care Complaints Commission.

Her death was the result of several failures in a system meant to care for her, he found.

She was taken to Campbelltown Hospital emergency department on July 18, 2013, after hours of puzzling behaviour, including lying on the floor and banging her head, making noises and crying.

Mr Dillion found carers at the Plane Tree group home, where Ms Hookey lived, were indecisive and failed to take early action.

And when she was sent for treatment, the emergency department was under intense pressure, having to deal with 56 patients with only 33 beds.

After Ms Hookey was seen by a doctor she was left on an ambulance trolley for two hours, despite a bed apparently becoming available soon after she arrived.

While in the ambulance bay, her condition was not correctly assessed, she was not given pain relief or fluids and wasn't sedated so her vital signs could be recorded accurately.

On top of this was some potentially discriminatory behaviour from the doctor.

During the inquest Natasha McFarlane, a team leader at the Plane Tree group home, gave evidence that in the resuscitation unit a doctor called the NSW Public Guardian and said: "Look at her, she's 29, if she was normal we'd treat her differently" in relation to attempts to bring her back to life.

The duty officer who took the call, Ms Gowan Vyse, took notes during and after the conversation, which came before the inquest.

"(The doctor) requested advice as to [whether] or not to resuscitate given her intellectual disability and quality of life," her notes say, according to the coronial findings.

Lawyers for the doctor argued that Mr Dillon could not be satisfied he said anything indicating discriminatory conduct, and that if he had it was out of character.

But, the coroner found it likely he had made the comment.

"The most benign interpretation that can be placed on his comments is that he thought that Shona was dying and that her quality of life was so poor that it would be a mercy for Shona not to be resuscitated," Mr Dillon said.

"But the law and ethical medical practice are not discriminatory in that fashion. Shona's life was no more nor less valuable to her than anyone else's is to him or her."

The doctor's performance, he added, was "sub-optimal."