Aboriginal and Torres Strait Islander peoples are advised this article contains the names and images of people who have died.
When Charlie Gowa woke up sick one morning, so sick he didn't want to eat his breakfast, his family knew something was wrong.
The six-year-old had a fever, diarrhoea, and when his mother, Xernona, finally convinced him to eat his breakfast, he vomited it straight back up.
She took him to Bamaga Hospital where they were given a re-hydrating iceblock, some Panadol and told to come back if his condition got worse. They were told it could be gastroenteritis.
Charlie did get worse.
He deteriorated overnight: his fever got so bad his skin was hot to touch and he was vomiting even without having eaten.
His parents took him back to the hospital, and were once again given Panadol and told to come back if his condition got worse.
Charlie went back to hospital every day for six days before he was eventually admitted.
Charlie was then flown to Cairns, and then Brisbane for treatment. It was in Brisbane that his family made the heartbreaking decision to turn his life support off.
He died of 'overwhelming sepsis' resulting from a rare bacterial infection - melioidosis - which is found in tropical climates.
Charlie's aunty, Madeleine Turner, said his death is a loss that is still felt deeply by his family and community.
"He had a lot of people in his family and in the community that really held a soft spot for Charlie," she told NITV News.
"He was a really uniquely bright and beautiful little boy. Still now some of the friends that he had in the community still come over and look for him.
"He was very special to a lot of people in the community because he was such a beautiful little spirit, a really calm but bubbly little boy."
Charlie's story was detailed in a report from the Queensland Office of the Health Ombudsman (OHO), which reveals the 'systemic issues' faced by his family in trying to seek help for him.
Charlie Gowa and his mum Xernona. Source: Supplied
The family's lawyer, Anna Talbot, a senior solicitor at the National Justice Project, said the report raises concerns about lack of cultural safety in health care and, in Charlie's particular case the record-keeping and assessment practices at the hospital.
"His first four presentations weren't even recorded by the hospital," she said.
"The fifth presentation noted that he'd presented previously but it was only on his sixth presentation that he was admitted and proper tests were done.”
'Could still be alive'
But Ms Talbot said this is not just a problem for Bamaga Hospital, or hospitals in regional and remote areas.
She said there is a 'broad and systemic problem' of failing to provide culturally safe health care for First Nations people in Australia, and Charlie is one of many people to be tragically impacted by this failure.
"These deaths should not be happening," Ms Talbot said.
"If they were receiving proper health care, if they were being kept in hospital and properly observed and properly treated, and treated with respect and dignity these people could still be alive today.
"These deaths should not be happening and it's really important that cultural safety plays a role in ensuring that's able to occur."
While the investigation by the OHO found there were systemic issues faced by Charlie's family in accessing care, it did not find his death was preventable or the that the 'actions of any individuals contributed to the tragic outcome'.
Charlie Gowa. Source: Supplied
The report sets out 20 recommendations that Ms Talbot said 'go to making sure something like this never happens again'.
She said there are a 'range of options' that the family can take in their next steps in seeking justice for Charlie.
"We will continue to consider our options as time goes by and the family makes decisions as to how they feel they can best seek justice for Charlie and their community," Ms Talbot said.
Madeleine Turner said she and Charlie's family want those responsible held accountable, and for no one else to ever go through what Charlie's parent have again.
"This should never have happened to Charlie and they should never have lost their son but if something can come from this that's positive for their community and family and for their people, that's what they want to see happen," she said.
"From here, our first steps are really just about sharing that story and people learning about Charlie, and we also want the people who are responsible to be held accountable for this and to acknowledge that.
"We don't want this to ever happen again. For Charlie's parents, they don't want to ever see another family go through this."
