The grieving parents of a six-year-old boy who died after repeatedly being turned away from a remote far north Queensland hospital are considering taking legal action following the release of a damning report into his death.

Warning: The following story contains images of an Indigenous person who has died.

Charlie Izaak Wilfred Gowa died from sepsis at a Brisbane hospital in January 2017.

The Queensland Office of the Health Ombudsman (OHO) has released a report detailing the “systemic failures” that led to his death.

The report details how Charlie’s mother, Xernona Poi Poi, took him to the emergency department at Bamaga Hospital in Cape York after he woke up not feeling well.

He had a fever, diarrhoea, and vomited up his breakfast.

He was sent home with Panadol and an ice-block.

Later that evening Charlie told his mother he was having trouble breathing.

The Ombudsman heard the family went back to the hospital every day for six days but each time were turned away with only Panadol offered as treatment.

The boy had become so weak he had to be carried to the toilet.

Charlie was finally admitted to Bamaga Hospital on January 10 — on the seventh attempt — and was then flown to Cairns where he was put in an induced coma and flown to Brisbane.

His condition did not improve and his parents made the decision to turn off his life support nine days after he was first taken to Bamaga Hospital.

The OHO report found he died of “overwhelming sepsis” caused by melioidosis.

Charlie normally a ‘happy, healthy boy’

Ms Poi Poi said her son was normally a strong and happy child.

“I tried so hard to get my son the help that he needed,” Ms Poi Poi said.

“These problems have existed for so long and they are still there today.

“I want better for my family and my community.”

The OHO report found Charlie’s case was an example of the “ongoing challenges and barriers the hospital and community face”, and made 20 recommendations for improvement, including better cultural awareness, clinical record keeping, and recognising deterioration.

The report did not find that Charlie’s death was preventable.

Family considering legal action

The family’s lawyer, Anna Talbot from the National Justice Project, said Charlie’s death was part of a “broader systemic issue”.

“The OHO report makes it clear that what happened to Charlie was the tragic culmination of widespread systemic issues affecting Bamaga Hospital and the Torres and Cape Hospital and Health Service,” Ms Talbot said.

“Despite most people in the region identifying as Aboriginal or Torres Strait Islander, the services there were not culturally appropriate to serve the community.”

She said the family were “examining their legal options”, but it would not be appropriate to comment further.

In a response to the Health Ombudsman, Torres and Cape Hospital and Health Service said it acknowledged the “loss of Charles Gowa and the distress and anguish of his parents and extended family”.

The service said it had conducted two of its own reviews into his treatment.

It said Bamaga Hospital services had developed significantly since 2017, including the improvement of clinical medial record systems and the addition of more permanent medical staff.