Young footy referee died in 'challenging' health system

Robert Murray was a "warm and obliging" young man, a devoted footy referee and avid supporter of his remote hometown team.

But at the age of 31, Mr Murray died of pneumonia at the small Collarenebri multipurpose health centre in northwest NSW on May 13, 2022.

State Coroner Teresa O'Sullivan has travelled to Walgett for a four-day inquest that will examine the adequacy of healthcare in the lead-up to the First Nations man's death.

Counsel assisting Tracey Stevens outlined Mr Murray's repeated visits to the health centre, where he was either seen remotely or by different nurses and doctors.

Mr Murray went to the health centre with chest pain on April 26 and his case was assessed by a doctor who was also working across both a hospital and a GP clinic at Walgett, 80 kilometres away.

On May 2, he returned to the Collarenebri centre with a bad cough and was later diagnosed with a chest infection at a separate GP clinic.

Nine days later, he experienced shortness of breath and saw two different GPs who flagged heart valve and renal issues and proposed follow-ups.

His cough worsened, as did his breathing, leading him and his mother to return to the Collarenebri medical centre about 1am on May 13.

A nurse on duty repeatedly tried to contact vCare, a 24-hour virtual support service staffed by clinicians at larger hospitals, but could only be connected at 2.03am.

"One minute or so after the call, Robert was observed having a seizure," Ms Stevens told the inquest during her opening address on Tuesday.

Mr Murray was pronounced dead about 3am, with his cause of death viral or bacterial pneumonia in the presence of heart disease and kidney issues.

Sarah Isaacs, the doctor who managed Mr Murray's care on April 26, was covering both the hospital and GP clinic at Walgett while also taking calls from a nurse about patients in Collarenebri.

"Generally if I was with a patient (in Walgett), I would ask if it was urgent and ask if I could call back ... so they could have my full attention."

Dr Isaacs said she was focused on Mr Murray's chest pain and was not aware of blood test results that indicated his poor kidney function.