Pregnant Woman Discharged From Hospital With Two Panadol Hours Before Death
A young Wiradjuri woman who died from a treatable sepsis infection received "inadequate" care in being discharged from an emergency department, a court has heard.
Naomi Williams, 27, was six months pregnant when she presented to Tumut Hospital in rural New South Wales late on New Year's Eve in 2015, complaining of pelvic pain.
After just 34 minutes, without seeing a midwife or doctor and without undergoing a pelvic exam, she was discharged. She was given two Panadol tablets for her pain.
About 15 hours later, she was rushed back to hospital by ambulance, where she was pronounced dead.
Her grieving family claimed racism within the healthcare system played a role in her death.
"I want to know whether race played a part in her death and I want Tumut Hospital to take responsibility for their role in Naomi's death," her mother Sharon Williams said.
"We love and miss Nay every day, maybe if she was listened to and taken more seriously she would still be here today."
Solicitor George Newhouse, who is representing the family, said Williams' requests for a specialist referral and for someone to look into the underlying cause of her ongoing pain went unheeded.
Instead, he said, she was often referred to drug and alcohol specialists, despite not having a drug or alcohol problem.
Williams had presented to hospital at least 18 times in the months leading up to her death.
"This is one of the saddest inquests I've had to attend," Newhouse said outside the NSW Coroner's Court on Wednesday.
"Naomi was a young, pregnant, Aboriginal woman looking forward to a life with her partner and young child, and instead today you see a grieving family."
Providing expert testimony to the inquest, registered nurses Jasmine Douglas and Eunice Gribbin -- neither of whom worked at Tumut Hospital -- agreed the level of care Williams received was inadequate.
"She ought to have been kept in emergency for a longer period of observation," Gribbin said.
Later, she added:
"34 minutes is just not adequate."
Williams' vital signs were taken twice, 15 minutes apart, the court heard. Her first set of vitals showed low blood pressure and an elevated heart rate, which both nurses agreed were concerning.
Fifteen minutes later, Williams' pulse had come down slightly, but her blood pressure had not changed -- a "not reassuring" observation, Gribbin said.
"It was not appropriate to discharge her," Douglas said, saying the Tumut staff on duty had "still not established a cause of her pain" and that "further assessments were necessary".
Both nurses agreed 15 minutes between taking vital signs was not a sufficient period of time to determine whether was stable, or if her vitals were trending in a safe direction.
"There were only two sets of vital signs which I think is insufficient," Douglas said.
Both nurses agreed the best course of action would have been to keep Williams in for longer observation, and alert a medical officer for further assessment.
Four hours would have been a good minimum observation time, Gribbin estimated.
At no point was Williams' pain measured out of ten, a self-determined score used by the medical profession to assess a patient's level of pain over time.
The midwife who attended to Williams the night before she died last year told the court:
"I probably didn't do a very good assessment of her pain. I just asked her and went by her appearance. She didn't appear to be in a lot of pain."
Both Gribbin and Douglas agreed that a pain score should have been done, particularly as pelvic pain was one of Williams' presenting symptoms.
The fact that she presented to hospital by herself on New Year's Eve was a "red flag", said Douglas.
Williams' cousin Graham Kilby remembered her as a beautiful, welcoming, loving woman.
"We'll never be the same. We lost someone so beautiful," he said outside court.
"My auntie lost not only her daughter but her only grandchild as a result of this negligence."
"It's systematic oppression of Aboriginal people that happens day in, day out, and we want justice. I need answers. Our family needs closure. This has been years. How much more do you need to scream. How much more do black voices need to be silenced?"
The inquest is expected to continue until Friday.
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