Naomi Williams died just hours after she was sent home from the emergency department. In addition to the death of Naomi Williams, we share the stories of Indigenous people who claim to have received inferior treatment at the same hospital.
WARNING: Aboriginal and Torres Strait Islander viewers are advised that the video above contains images of deceased persons.
In the first few minutes of 2016, when many people were celebrating the New Year, 27-year-old Wiradjuri woman Naomi Williams was driving herself to hospital.
Ms Williams was six months pregnant and this was her 18th visit to the hospital in the past eight months. That night, she was given two Panadol and monitored for just over half an hour, then sent home.
Fifteen hours later she was dead.
Ms Williams’ family say she had felt racially discriminated against by hospital staff in the past- and that this may have contributed to her death.
“Racism definitely played a part in it,” says Ms Williams’ mother Sharon Williams.
I don't want to go up there, they just, they treat me like a junkie.
Naomi Williams’s childhood friend, Talea Bulger, says that despite suffering from chronic stomach pain and persistent vomiting since early 2015, Ms Williams was hesitant to go to the hospital.
“She would say ‘I don't want to go up there, they just, they treat me like a junkie’ and… they didn't want to take care of her,” says Ms Bulger.
A coronial inquest is trying to find out how Ms Williams died, and the answer could change how Indigenous people, and their health, are treated.
“I do think that Naomi's case could be a watershed for change in Australian medical history,” says George Newhouse, the lawyer representing the Williams family at the coronial inquest.
“The Coroner has the power to make recommendations to improve public health, to ensure that deaths like this don't happen again.”
'Stereotyped as some sort of drug addict' says mother
Ms Williams started to get sick in early 2015. She was frequently nauseous, vomiting and in pain.
Ms Williams’ family say she was only an occasional marijuana smoker, and as her nausea and stomach pain continued, she turned to that for pain relief.
After multiple tests and scans, the hospital was unable to give her a clear diagnosis. The hospital repeatedly referred her to drug and alcohol counselling.
When Ms Williams was assessed by that drug and alcohol service, they found she was not an addict.
However, the hospital staff continued query whether her symptoms were due to marijuana withdrawal.
Sharon Williams, based two hours away in Canberra, became increasingly frustrated by her daughter’s treatment.
On the 30th of July 2015, Sharon Williams wrote an email to the director of nursing staff at Tumut Hospital, stating that her daughter “feels her illness is being overlooked and she feels stereotyped as some sort of drug addict.”
She pleaded for her daughter to be referred to a specialist, but the director of nursing staff replied that referrals are made by the doctor, and Naomi Williams was receiving “world class care.”
By September, even though Ms Williams’ symptoms were the same, her situation wasn’t – she was pregnant. Her diagnosis changed to hyperemesis gravidarum, a form of extreme morning sickness.
“You'd have to say after 18 presentations, someone would have thought to refer her to an expert, and that just didn't happen,” says Mr Newhouse.
“I think that the lack of trust that had developed between Naomi and hospital staff may have impacted on her decision not to return to the hospital in the hours before she died.”
What happened to Naomi Williams?
On the 1st of January 2016, Ms Williams was fading fast.
“She lost body functions, so I got her to the shower to bring her temperature down and that,” says her partner, Michael Lampe.
“I got her to the lounge. That's when she told me she couldn't feel her legs.”
An ambulance was called, but Ms Williams had a cardiac arrest en route to Tumut Hospital.
An autopsy report later revealed that the cause of death was unrelated to Ms Williams’ ongoing vomiting and nausea issues.
She had sepsis, associated with the bacterium Neisseria meningitides (which can cause meningococcal disease). This is a serious infection, but one that that is treatable with antibiotics if caught early.
The first week of Ms Williams’ coronial inquest in September 2018 detailed her treatment early on New Year’s morning.
Hospital records state that Ms Williams was attended by two nurses who noted she had generalised aches and pains and had not vomited ‘since yesterday’.
One nurse took her vitals at 12:20 AM, with four bordering on the ‘yellow zone’ – an early warning sign of deterioration.
A nurse gave Ms Williams two Panadol, and checked some, but not all, of her vital signs, twice in 15 minutes. When those signs fell within normal limits, Ms Williams was sent home. From the time Ms Williams arrived to the time she left, 34 minutes had elapsed.
At Tumut Hospital, doctors are not always on-site and must be called in. Nurses later told an inquest that the fact it was early on New Year’s morning did not influence their decision whether to call a doctor.
Ms Williams’ family and legal team believe she was not properly assessed that night.
“The standard maternity observation chart has a section that requires a pain assessment. She's complaining of pain and yet no pain assessment was done,’ says Mr Newhouse.
“Probably thinking, ‘Oh here she comes again,’” says Sharon Williams.
The inquest also revealed that nurses may have missed vital information when Naomi Williams turned up at the hospital for the last time.
On the 17th of December, Ms Williams’ doctor noted that she was as a “high risk” maternity patient, but she failed to communicate this with staff at the hospital.
It was also revealed that one of the nurses who treated Ms Williams that night had not done the necessary training to identify sepsis in pregnant women.
Watch the full story above.
'Cluster of complaints' says lawyer
In late 2017, The Feed was present at a community meeting in Tumut where Indigenous locals informed Mr Newhouse and a team of lawyers about their alleged mistreatment at Tumut Hospital.
“There were other cases which seem to suggest that there was a cluster of Aboriginal people who are complaining of discrimination and prejudice,” says Mr Newhouse.
“They felt that they weren't being listened to, that they were just being told to go away,” says former Tumut Mayor Sue Bulger, who was present at the meeting.
“Most people that Aboriginal community deals with are terrific people. It is perhaps just a small number of people who immediately see that Aboriginal face and their treatment changes.
“I have heard quite a few stories… some more tragic than others,” says Ms Bulger.
One of these stories was that of local Indigenous woman Colleen Freeman.
A few years before Naomi’s death, Ms Freeman was regularly presenting to Tumut Hospital with persistent and strong headaches.
The Feed has heard claims that Ms Freeman received minimal treatment, and was often sent home with nothing more than Panadol. She later died of a brain aneurysm.
This is just one of the cases in this town, with striking similarities to the case of Ms Williams.
Just a few months after Ms Williams passed away on New Year’s day, 37-year-old Indigenous woman named Naomi Ward turned up to Tumut Hospital nauseous, dizzy and vomiting.
Mr Ward was entering the final stages of life-threatening septicaemia. After hours of excruciating pain, she says the nurses at Tumut Hospital told her to pull herself together.
“They said that I was just being pathetic,” says Ms Ward. “I also tried to go to the toilet and she grabbed hold of my arm and she said ‘No, you're not going to the toilet just to shoot up’.”
Ms Ward does have a history of drug use, but at the time she fell sick, she says she had been clean for more than a decade.
“I think they thought I hadn't used drugs in a very long time and I'd slipped up, and I'd had too much, and that was it. I was gonna sleep it off or something.”
After Ms Ward collapsed later that night, she was flown to Canberra. She was in a coma for weeks, and eventually had her legs and many of her fingers amputated.
“I had septicaemia and apparently E. Coli in my left lung,” says Ms Ward.
Ms Ward believes her treatment that night was partly due to discrimination because of her race.
“They don't care … someone that's white, you will get help, but you won't otherwise,” she says.
The Feed asked NSW Health to respond on-camera to local Indigenous people’s claims of discrimination and inferior treatment experienced at Tumut Hospital.
Instead, a representative from the Murrumbidgee Local health district sent a statement saying “Murrumbidgee Local Health District (MLHD) takes all patient complaints extremely seriously.”
“All concerns raised are thoroughly investigated to determine if any improvements can be made to patient care,” the statement continues.
MLHD outlined a series of recent improvements at Tumut Hospital in relation to the care of Indigenous patients, including increased in-person cultural awareness training, additional online training for all staff, and the appointment of two Aboriginal representatives appointed to the Local Tumut Health Advisory committee.
They also stated: ‘As the Inquest into the death of Naomi Williams is continuing, it is not appropriate for MLHD to comment further at this time.’