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'The System Let Naomi Down': Coroner Finds 'Implicit Bias' In Death Of Indigenous Woman

The family of a Wiradjuri woman who died after being prematurely discharged from hospital said the country's healthcare system has been "put on notice" over its treatment of Indigenous people. 

Aboriginal and Torres Strait Islander people are warned this article contains photos of a person who has died.

Naomi Williams was 27 years old, and six months pregnant, when she presented to Tumut Hospital in rural NSW. It was New Year's Eve, 2015, and she was complaining of pelvic pain.

The disability worker, who relatives say was "passionate" about social justice, had attended hospital 15 times in the months prior. She was discharged after 34 minutes, without seeing a midwife or doctor or undergoing a pelvic exam.

Williams died the following afternoon from septicaemia -- a complication associated with a treatable infection called Neisseria meningides.

Naomi Williams. Photo: Supplied.

A three-year coronial inquest has concluded Williams should have received further treatment on the morning of her death, and that her prior presentations had reduced her expectations of her care.

Handing down her findings on Monday, Deputy State Coroner Harriet Grahame acknowledged and made recommendations to address "implicit bias" in the provision of healthcare for Indigenous Australians.

"What was important about this inquest was that the truth came out," Solicitor George Newhouse, who is representing the family, said outside a packed courthouse in Tumut.

We deny the implicit bias and prejudice that exists in our health system and in other arms of the government.

"That's what lies at the heart of the inquest -- the implicit bias that the coroner has identified and did refer to in her findings."

READ MORE: Pregnant Woman Discharged From Hospital With Two Panadol Hours Before Death

Naomi Williams was in "the prime of her life" before her death. A young Wiradjuri woman, she had a loving partner, a tight-knit local community, and a new baby on the way.

"Naomi loved music, movies, painting and writing poetry about the river and her family," her cousin, author Dr Anita Heiss, said on Monday. 

"She was passionate about social justice, excited about being pregnant with her first child. She was highly respected for the strong, hardworking Wiradjuri women that she was." 

Naomi Williams' cousin Dr Anita Heiss. Photo: AAP

The inquest heard Williams had an "exceedingly high" number of presentations to the hospital's emergency department between May 2015 and her death, through which she received "brief symptomatic treatment rather than necessary investigation of underlying causes".

She was often referred to drug and alcohol specialists, despite not having a drug or alcohol problem.

Grahame concluded these frequent presentations "likely led to her having reduced expectations of care".

She also found Williams should have received further examination by hospital staff on the morning of her death.

READ MORE: Inquest Into Death Of Pregnant Indigenous Woman Begins

"On the basis of some of the clinical information known and recorded at the presentation, Naomi should have been further investigated," Grahame said.

"She was discharged earlier than clinically indicated, after which she deteriorated from septicaemia associated with Neisseria meningitides infection."

Heiss said her cousin had felt "invisible" to the healthcare system.

"We are reminded today that Naomi was desperate for healthcare, but her pleas were not heard by the health service in Tumut," she said. 

"Naomi,  like most of us here, was an Australian citizen with rights to appropriate healthcare. But the system let Naomi down. We know that, she knew that, and now through this inquest, it has been proven that the treatment that Naomi received from Tumut Hospital was way below any acceptable standard."

I think the reality is if Naomi had presented to Tumut Hospital as a non-Indigenous person ... her treatment would have been completely different.

Williams' family accepted and welcomed the many recommendations Grahame made to the Murrumbidgee Local Health District.

These included providing staff with training sessions on the importance of safety alerts, strengthening the Aboriginal Health Liaison Worker program to ensure workers are available 24 hours each day, and adopting targets within the local health district for employment and retention of Indigenous healthcare professionals.

She also recommended establishing targets for the proportionate representation of Indigenous people on the local health advisory committee and board, and introducing tools to measure the possibility of "implicit bias".

Heiss said the family "hoped and fully expected" the recommendations would be implemented.

"Moving forward, we need to believe that lessons have been learnt and that changes will be made to the health system -- not only in Tumut, but across the country," she said.

"We hope that in Nae’s death, other lives will be regarded with more respect. 

"This inquest has put the health system in notice."

Contact the author at ebrancatisano@networkten.com.au