The day 18-year-old Betty died from rheumatic heart disease complications, the two locum doctors providing care in her final hours had no time for a handover.

The incoming locum arrived at 3pm on 23 September 2019 as the outgoing locum raced to meet the small aircraft waiting on the tarmac in the isolated Queensland community of Doomadgee, 2200km north-west of Brisbane.  

At the time, neither was aware of the seriousness of her condition. 

“While no-one in that specific moment at 3pm could have foreseen the medical emergency unfolding then and there resulting in Betty’s death approximately 4.5 hours later, … she was declared formally deceased at 7.45pm,” read the findings of Queensland’s northern coroner, Nerida Wilson.