Experts told a court that a pregnant Indigenous woman who died from a serious but treatable infection should have been seen by a doctor before she was discharged from a NSW rural hospital.
Naomi Williams, a 27-year-old Wiradjuri woman, and her unborn baby boy died at the Tumut District Hospital on January 1, 2016.
Ms Williams arrived at the emergency department around midnight complaining about abdominal pain, was given paracetamol and discharged after 34 minutes.
Fifteen hours later Ms Williams was dead. An autopsy showed the cause of death was a bacterial infection (meningococcal) and blood poisoning (sepsis).
An inquest, which began in Gundagai last year, resumed in Sydney on Wednesday before deputy state coroner, Harriet Grahame.
Hospital discharge 'inappropriate'
When she presented, Ms Williams' vital signs – temperature, pulse, respiration rate and blood pressure – were recorded as being just outside what the hospital calls the "yellow zone," an early warning sign of deterioration.
Her blood pressure improved 15 minutes later and she was sent home.
Two registered nurses and educators - Eunice Gribbin and Jasmine Douglas - were called as expert witnesses and asked about the best clinical practice under the circumstances.
"The observations taken were not very reassuring in my mind," Ms Gribbin told the court.
"Often clinicians can jump to conclusions."
Ms Williams had presented to Tumut hospital 18 times in seven months but nurses did not check her medical history - including that a doctor had identified her pregnancy as being ‘high risk’.
"Her history was not sought and she had been a patient of that hospital many times," Ms Gribbin said.
Ms Douglas also told the court that she felt that further assessments were necessary at that time.
"This is a young woman who felt unwell enough to take herself alone to an emergency department after midnight on New Year’s Eve," she said.
"I think it was inappropriate to discharge or let her go at that point in time because they still had not established the cause of the pain."
'We want answers'
National Justice Project solicitor, George Newhouse, said discrimination was a "silent killer" in the healthcare system.
"Naomi presented at least 18 times to Tumut Hospital in the months before she passed away,” he told reporters.
"She was sick and required assistance but felt that no one was listening to her. She was often referred to drug and alcohol [services] when she had no drug and alcohol problems."
One of Ms Williams' cousins, Graham Kilby, said the family was “heartbroken” and needed justice.
"My aunty not only lost her only daughter, but her only grandchild," he said. "How much more do you need to scream? How much more do black voices need to be silenced?"
"Our family needs closure. We're struggling."
Another cousin, Indigenous writer Anita Heiss, said she wanted to make sure no other family was “left heartbroken by negligence” and for the hospital to take responsibility for the death.
"We want to know if race has played a part in this," she said. "We want answers and I think, most of all, we want to make sure this never happens again."