A medical professional in one of Australia's hospitals talks to a patient. (AP)

A coroner in Queensland has come to the conclusion that institutional racism was behind the lack of competency in healthcare providers that resulted in the deaths of three indigenous women.

The three Aboriginal women came from the isolated Doomadgee town in northwest Queensland, Australia.

Coroner Nerida Wilson stated in a 137-page report that the deaths of Doomadgee residents Adele Sandy in 2019, aged 18, Yvette Booth in 2020, aged 17, and Shakaya George in 2020, aged 27, were brought about by complications due to rheumatic heart disease (RHD) and could have been avoided with adequate care.

Wilson went on to say that a lack of teamwork among Doomadgee's health services, a failure to offer proper treatment, and a lack of "cultural competency" had resulted in a "complete and fundamental breakdown of trust" between the community and the health personnel that served them.

Multiple agencies had not properly communicated according to Wilson, leading to a fragmentation of vital health information which threatened the “data sovereignty” of patients.

According to the coroner, many other reasons led to the death of the women, such as a lack of a formal RHD screening program, trouble keeping staff trained in cultural competency, lack of access to proper nutrition, and many more.

Wilson's report concludes that the health services are in need of a reset, adding that "all involved, individuals and organizations, have acknowledged the circumstances of the deaths and identified the gaps … All say they want to do better.”

Queensland’s chief First Nations health officer, Haylene Grogan, responded to the coroner's report by stating that the passings of the women "are a tragic reminder of the ongoing inequities that First Nations people face."

"It is with deep sadness that I acknowledge the sorry business experienced by their loved ones and the extended period of sadness in Doomadgee for their recent losses.”

Shannon Fentiman, the state health minister, disclosed that the government took all 19 of the coroner's recommendations seriously and “will work with the Doomadgee community, including elders and local health providers, to respond appropriately.”

Wilson added that “health system leadership and providers have a clear role resetting health services and healthcare delivery while ceasing to be complicit in the injustices and inequities in healthcare systems."

According to the coroner, institutional racism has been a lasting issue in the health sector of Queensland.

In 2017, the Queensland Human Rights Commission and the Queensland Aboriginal and Islander Health Council (QAIHC) found racism to be prevalent at multiple health facilities.

In early June, a report by the Queensland auditor-general explained that “Queensland Health must improve how it delivers culturally appropriate care," suggesting that a coordinated strategy should be in place to ensure Aboriginal people from remote and rural areas attend specialist outpatient appointments, and calling for measures to see how effective Queensland health delivers culturally appropriate care.

Wilson concluded her report by noting that at "an institutional level, it is essential that racism in all its forms, reasons, oral and by action can be identified, measured and monitored.”