Ricky Hampson Jr's family remember him as a strong and brave boy, who grew up to be a loud, kind and happy man.
"But as strong and brave as he was and as warm and caring as he was and as loud as he could be, when he needed help no one heard him," his father Ricky Hampson Sr said on Friday.
An inquest into the death of Mr Hampson Jr, from ruptured duodenal ulcers after being misdiagnosed at Dubbo hospital, has finished hearing evidence revealing a series of medical errors.
The 36-year-old Kamilaroi-Dunghutti man died at a friend's house on August 16, 2021, less than 24 hours after he was discharged from the hospital in western NSW.
Mr Hampson Jr, also known as Dougie, went to the emergency department on August 14 in "10 out of 10 pain", after feeling a tearing or popping sensation in his abdomen.
Emergency doctor Sokol Nushaj told the inquest "cognitive bias" led him to misdiagnose Mr Hampson Jr with the drug-related condition cannabinoid hyperemesis syndrome.
The senior doctor said he recognised symptoms of agitation and pain when Mr Hampson Jr was wheeled to an emergency bed and closed his mind to other alternatives.
Dr Nushaj, who was overseeing a busy department at the height of the COVID-19 pandemic, said Mr Hampson Jr's history of cannabis use and blood test results also influenced the diagnosis.
But he acknowledged Mr Hampson Jr did not have the key symptoms of vomiting and nausea, and he was not sent for scans to confirm the source of his acute pain.
Deputy State Coroner Erin Kennedy has been asked to consider whether racism and bias played a role in Mr Hampson Jr's treatment.
Stuart Kettle, the barrister representing the Western NSW Local Health District, said the inadequate care was due to several "omissions" rather than bias.
"The evidence does not support a finding that the omissions by those who provided the medical (care) ... can be attributed to his being an Aboriginal man," Mr Kettle said in his closing submissions in Dubbo on Friday.
The inquest has been told the diagnosis meant Mr Hampson Jr was not reviewed or re-examined before he left the hospital, despite having a high heart rate and ongoing pain.
Mr Kettle said the health district and the hospital have worked hard to improve healthcare for Indigenous patients.
"They have been so committed for many years."
Outside court, Mr Hampson Sr said all hospital staff should be trained on culturally safe care and the district should collect data on incidences of racism to understand how deep the problem might be.
The family also want a memorial to Dougie at the hospital to ensure he is never forgotten.
"Getting these reforms won’t bring Dougie back, nothing will do that," Mr Hampson said, his two daughters standing by his side.
"If we can save the lives of other First Nations people through these reforms, it will be the first step towards healing the pain my family and I carry inside us."
The coroner will hand down findings and recommendations at a later date.
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