Inquest into the death of Naomi Jane Williams

6 mins  01.08.2019

On 29 July 2019 the State Coroner's Court of New South Wales released findings into the death of Naomi Jane Williams from septicaemia, secondary to Neisseria meningitides infection.

The Coroner's inquest concerned contentious evidence surrounding the circumstances of her death, including whether Naomi Jane Williams care was affected or compromised by unconscious, implicit bias or racism. Accordingly, the Coroner made a number of recommendations to the Murrumbidgee Local Health District.

Background Facts

Naomi Jane Williams (Ms Williams) was a 27 year old Wiradjuri woman and 22 weeks pregnant at the time of her death. She had an exceedingly high number of presentations to the Tumut Hospital (the Hospital), and general practitioners during the period of 21 April 2011 and 1 January 2016.

The Coroner detailed Ms Williams comprehensive medical history. Ms Williams had a longstanding and retractable condition that included vomiting, abdominal pain and dehydration. Ms Williams was often prescribed medication as a reactive response and infrequently admitted to hospital. Progress notes indicated that Ms Williams smoked marijuana 'on and off.' She received referrals for treatment of her infrequent marijuana use.

The frequency of Ms Williams visits to the Hospital and rooms of general practitioners increased in the period between 10 May 2015 and 1 January 2016. Ms Williams presented at the Hospital and to general practitioners over eighteen times in the seven months before her death.

Ms Williams mother stated that whilst her daughter used marijuana she was 'stereotyped as some sort of drug addict' and her daughter wanted to see a specialist. Further her mother gave evidence that Ms Williams felt as though she was not being taken seriously.

On 1 September 2015, Ms Williams presented to the Hospital vomiting and was diagnosed as pregnant. On 1 January 2016, at approximately 00:15 hours, Ms Williams again presented to the Hospital. Ms Williams partner stated Ms Williams was ill, vomiting, suffering headaches as well as back pains and spasms prior to driving herself to the Hospital's Emergency Department on 1 January 2016.

Ms Williams was assessed jointly by a Triage Nurse and Midwife. She was given Panadol at 12:25 hours. At 00:53 hours Naomi was discharged and drove herself home. At approximately 14:30 hours, Naomi returned to the Hospital by Ambulance in cardiac arrest, she had collapsed at home and was unresponsive. Resuscitation delivered at the Hospital was unsuccessful and at 15:08 hours on 1 January 2016 she was pronounced deceased.


It was established to the requisite standard, at the outset of the Coronal Inquest that Ms Williams had died on 1 January 2016 at Tumut Hospital, NSW. Further, the medical cause of her death was confirmed to be septicaemia, secondary to Neisseria meningitides infection.

The Coroner stated that the issue of the Coronal Inquest were the broader circumstances surrounding the "manner" or circumstances of Ms Williams death, specifically, whether the care provided to Naomi was affected or compromised by unconscious, implicit bias or racism.


Ms Williams died at Tumut Hospital, New South Wales, from septicaemia, secondary to Neisseria meningitides infection. An autopsy performed on Ms Williams showed generalised micro-thrombi in the small arteries throughout her body and sub-endocardial haemorrhage in the left ventricle of the heart, both consistent with septic shock.

The Coroner found that Ms Williams frequent presentations/admissions to the Hospital prior to her death, where she received brief symptomatic treatment, rather than necessary investigation or specialised intervention of underlying causes, would likely have led to her low expectations of care.

The Coroner found that when Ms Williams presented to the Tumut Hospital on the morning of her death, it was unknown that her pregnancy was high risk, as the information had not been flagged. Further, it was not known that Ms Williams was suffering from a bacterial infection, which was life threatening. The Coroner found that Ms Williams presentation on the night of her death, should have triggered further investigated by the Hospital. She was discharged earlier than was clinically indicated. Ms Williams should have received further examination on the night she died.

The Coroner concluded that the care the Hospital provided to Ms Williams family, following her death was not compassionate or appropriate.

Further, it was found that Ms Williams care was affected by unconscious and implicit bias or racism. The Coroner highlighted the well-known disparity between health care outcomes of Aboriginal people and those from non-Aboriginal population, namely, a lot of Aboriginal people 'feel they cannot go up to the Hospital as they won't get the treatment they need.' The Coroner heard evidence that stereotyping of Indigenous people as more likely to use drugs and alcohol impairs best decision-making by the healthcare industry. The Coroner acknowledged, based on the evidence heard at the Coronial Inquest, that unequal treatment and state wide health outcome inequality among Aboriginal people is prevalent and affected the care provided to Ms Williams.


Accordingly, several recommendations were made to the Murrumbidgee Local Health District (MLHD).

The Coroner made the following recommendations:

  1. that consideration be given to providing a training session to staff on the importance of safety alerts, including "high risk pregnancy" and a consistent method for implementing such alerts is communication to all staff;
  2. that consideration is given to implementing a Nurse Directed Emergency Care policy;
  3. that consideration be given to strengthening the Aboriginal Health Liaison Worker program through ensuring workers are available 24 hours a day and all staff are aware that the NSW Health Policy "Notification/referral of Aboriginal Inpatients (MLHD PROC208) applies to patients who present at the Emergency Department as well as those who are admitted;
  4. that consideration be given to adopting targets within the MLHD for the employment and retention of Indigenous health care professionals in numbers at least equivalent to the number of Indigenous residents in the local area;
  5. that consideration be given to auditing the possibility of implicit bias by recording statistics for Indigenous and non-Indigenous patient triage categories, discharge against medical advice, triage times and referrals for drug and alcohol reviews for patients presenting to the Emergency Department at Tumut Hospital;
  6. that consideration be given to identifying other assessment tools to measure the existence of implicit bias on the provision of health care and commit to making such tools available to Tumut Hospital;
  7. that consideration be given to establishing targets for the proportionate representation of Indigenous people (by population and no less than two) on the Local Health Advisory Committee and MLHD Board;
  8. that consideration be given to establishing ongoing consultation process with the Healthy Enriched Aboriginal Living Mawang (Together) Group with a view to developing a strong local model for providing culturally safe heath care, in line with initiatives implemented by Hunter New England Health; and
  9. consideration be given to seeking immediate consultation with Hunter New England Health in relation to strategies for developing culturally appropriate care, in line with the detailed model they have developed.

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