These were just some of the failings of Dubbo Base Hospital revealed in a recent NSW inquest into the death of 36-year-old Kamilaroi Dunghutti man Ricky Hampson Jr after being discharged from the hospital in 2021.

But it's not the first time any of these issues have come to light after an inquest into Dubbo Hospital.

The Daily Liberal looked back at four previous coronial inquests into the hospital over the past decade to see the parallels these cases had.

Throughout his overnight stay at the hospital Mr Hampson Jr was not checked up on by a doctor and the senior doctor who diagnosed him did not make notes of his observations.

Poor note-taking and failure to observe patients also came up during an inquest in April and June, 2015, into the death of 46-year-old Lynette Maree Young.

Ms Young died at the hospital on April 29, 2012, less than a week after starting treatment at the hospital's chemotherapy unit following surgery in Sydney to remove a melanoma.

On the morning of April 28, Ms Young awoke in pain and her partner drove her to Wellington Hospital. There, a doctor took a heart rate reading before a decision was made to transfer to Dubbo Hospital.

She was first seen by doctors in the emergency room where it was determined her pain was consistent with heart attack or a viral infection. The doctors did not record a number of their findings.

"Contrary to policy", Ms Young did not receive hourly vital signs observations after arriving at the emergency department. She was supposed to be placed in a monitored bed but she was admitted to an unmonitored bed.

By 10am the next morning, she was "pale and unwell", was still in pain and had a high heart rate.

Concerned, Dubbo Hospital doctors phoned a cardiologist at Orange Hospital and he suggested that further scans be done on Ms Young. However, no technician who could do those scans was available and arrangements were made to transfer her to Orange

But, at 3:21pm, Ms Young went into cardiac arrest. Despite the efforts of medical staff, Ms Young was declared dead less than an hour later.

At the end of the inquest presiding coroner H Barry said the level of care given to Ms Young "can be characterised in part by a series of failures by the staff and the system".

"These included inadequate observations and poor recording of notes and observations, inadequate handover, failure to recognise her deteriorating condition and failure to initiate a MET call at an appropriate time," he said.

Staff's failure to check up on patients came up again during an inquest in June and October 2017 which explored the circumstances around the death of a 28-year-old man at Dubbo Hospital's mental health inpatient unit.

On February 28, 2014, the young man took his own life while staying at the hospital as an involuntary inpatient. Nurses on the ward found him dead in his room at around 5:20pm.

The man had a long history of mental illness involving severe depression, persistent suicidal ideation and previous attempts at self-harm and suicide.

He was assigned as observation Level 2, which meant that nursing staff was to check up on him every 15 minutes.

On the afternoon of the man's death he entered his room at about 2:41pm and nurses recorded observations at 3pm, 3:15pm, 3:30pm and 3:45pm.

However, CCTV footage showed no clinical staff attended either in, or near, the man's room between 2:41pm and about 5:20pm when he was found dead in his room.

One of the nurses was interviewed during an internal investigation by the Western NSW Local Health District and admitted she did not leave the nurses station but simply signed the observation sheet. She said this happened regularly in the ward.

State coroner Teresa O'Sullivan found around the time of the death policies around observing patients in the mental health ward and recording observations were "either routinely misapplied, or routinely ignored".

She said nurses had not been provided by their employer with any formal training or instruction in relation to the conduct of patient care level observations.

Among her recommendations were a number of changes to the way patient observations are documented and recorded, including further training for staff.

"[The man's] tragic death has highlighted serious shortcomings in relation to the Local Health District's policies and compliance with them," Justice O'Sullivan said.

A parallel can also be drawn between the experience Mr Hampson Jr had at Dubbo Hospital with the experience of a 56-year-old Indigenous man in 2014.

Like with Mr Hampson Jr, a coronial inquest into the man's death in October 2018 found no Aboriginal health workers were available at the hospital to help him.

During a trip to Coffs Harbour in early January 2014, the man cut his left big toe on an oyster shell. The wound became infected and he returned to his home in Mendooran.

On January 19, his daughter noticed the cut was swollen and looked inflamed and he was unable to put shoes on. Two days later, he went to the Bawrunga Medical Centre in Dubbo and was referred to the emergency department at the hospital.

A registrar on duty cleaned and bandaged his wound and gave him a short course of IV antibiotics. He was also discharged with oral antibiotics.

But a week later his infection had increased and he went back to see his GP who sent him back to hospital where he stayed. On January 30 a surgeon told him he would need surgery to remove the dead and infected tissue.

He went in for surgery the next day, which fell on the weekend. Aboriginal Health Workers are not available on weekends or after hours.

Before the surgery began the anaesthetist gave him a full general anaesthetic.

The surgery took about 30 minutes and the surgeon considered the procedure had gone well. He left while the nurse and anaesthetist waited for the man to regain consciousness but, tragically, that never happened.

Doctors noticed his oxygen levels had dropped and his heart was not pumping any blood. After hours of work, doctors were able to restart his heart and lungs but his brain was injured as he had been without oxygen for too long.

The man remained on life support at Dubbo Hospital until he was transferred to Nepean Hospital in early February for further assessment. There, the family decided to turn off life support on February 6, 2014.

Coroner Les Mabbutt said the man's death was preventable.

"DH's family understood he was undergoing a minor surgical procedure on his big toe and had no cause for concern," he said.

"DH's death in those circumstances increases the grief and loss felt by his family making his death difficult to reconcile.

"It occurred due to failures in his care and treatment whilst a patient at Dubbo Hospital, a place where members of the community must entrust their care into the hands of medical professionals,"

An aspect of Mr Hampson Jr's hospital stay explored in the inquest was whether he should have been discharged and whether the hospital's discharge procedures were adequate.

This also came up during a coronial inquest into the deaths of Judith Chrupalo and Christopher Clee held in March 2021, just months before Mr Hampson Jr's hospital stay.

Ms Chrupalo, 74, and Mr Clee, 54 - a mother and son - were found dead in their Windsor Parade home on March 9, 2016.

A neighbour had called police to conduct a welfare check as they had not seen the pair for a number of weeks. When police arrived, they found the house was in squalor and the bodies of Ms Chrupalo and Mr Clee in "an advanced state of decomposition".

A post mortem found Mr Clee likely died of natural causes as a result of his poor health and Ms Chrupalo - who relied on him for her care - likely died of starvation sometime afterwards.

Dubbo Hospital came under scrutiny as Ms Chrupalo had been a patient there twice in 2015.

The first, on June 16, Mr Clee called an ambulance for his mother because she "had lost her appetite for the last week". Attending paramedics noted that the house was unkempt and Mrs Chrupalo was lying in urine stained sheets and faeces.

She stayed in hospital overnight where her health improved, however, on June 18 paramedics attended the home again after she fell and Mr Clee was unable to lift her. Paramedics again noted "poor living conditions" in the home.

The second hospital admission was on June 19. Mr Clee called an ambulance for Mrs Chrupalo saying his mother was unable to get out of bed and couldn't cope at home.

She remained in hospital until July 8 and was discharged against medical advice.

Deputy state coroner Derek Lee identified a number of issues in Dubbo Hospital's decision to discharge Ms Chrupalo.

Justice Lee recommended the hospital review procedures for discharge against medical advice, improve discharge planning and better train staff in identifying elder abuse.

He said that the hospital may have failed to recognise neglect as a form of abuse and should not have let Ms Chrupalo go home under Mr Clee's care.

"This inquest has emphasised the need to protect older persons, and the members of our community who are most vulnerable and socially disconnected, from potential harm," Justice Lee said.

Asked about these inquests and the similarities to Mr Hampson Jr's case, a spokesperson for the Western NSW Local Health District said the district takes all recommendations "incredibly seriously".

"All recommendations made are carefully reviewed and assessed to determine if and how they can be appropriately implemented," a spokesperson said.

"The District has strict processes in place to review serious and unexpected patient outcomes and to act on any identified areas where improvements can be made.

"This includes referral to the NSW Coroner where required, and active participation in any subsequent investigations."

The spokesperson said recommendations made by the coroner are "carefully considered" in the context of changes or improvements already made and are adopted where appropriate.

"A wide range of improvements and developments have been made at Dubbo Hospital across the past 10 years with a continuing focus on enhancing local and outreach services, improving patient's access to and experience during care, and developing the workforce," they said.

In the 2022 Bureau of Health Information Adult Admitted Patient Survey, 92 per cent of patients rated their care at Dubbo Hospital as either 'very good' or 'good', and 94 per cent rated both the doctors and nurses who treated them as 'very good' or 'good'.

"Dubbo Hospital, and the Western NSW Local Health District have an absolute commitment to clinical safety and, where patient outcomes do not meet expected standards, to reflecting and making changes to ensure all patients receive the highest possible standard of care," the spokesperson said.