A grieving family is reliving their daughter’s painful final months of life as a coronial inquest searches for the real cause of her death.
Naomi Jane Williams was 27-years-old and six months pregnant when she arrived at Tumut Hospital shortly after midnight on January 1, 2016 complaining of severe pain in her hips.
That morning marked the 18th time she went to the hospital complaining of extreme pain, vomiting, nausea, or a combination of those over just seven months.
She was run through some basic tests, given some Panadol, and sent home just 34 minutes after she arrived.
About 14 hours later, Ms Williams and her unborn baby died during a heart attack.
An autopsy later revealed Ms Williams almost certainly died from sepsis associated with Neisseria meningitidis, a condition that is usually treatable with antibiotics.
Counsel assisting the coroner Lesley Whalan said the inquest will explore whether the fact that Ms Williams was Aboriginal played any part in her treatment by the hospital.
"The high number of presentations to the hospital that Naomi made over that period of seven months or so to January 1 gives rise to questions about the way Naomi was assessed,” she said.
“There is substantial evidence at this point that, over the period from May, 2015 to January, 2016, Naomi’s perception was that her illnesses were not taken seriously by the staff at Tumut Hospital and no one knew what was wrong with her.”
Nurse Shirley Adams, who treated Ms Williams that morning, was called to give evidence on Monday.
Ms Adams, a registered nurse of 40 years, said Ms Williams looked “blossoming from pregnancy” when she arrived at the hospital that morning.
“I asked her what was the problem and she said she had pains in her hips from the baby,” Ms Adams said.
“Naomi said that she hadn’t been sick for two days – hadn't vomited – I think she said the last couple of days.”
Ms Adams and the nursing staff then addressed her as a triage category five – the least urgent of all categories in the emergency department.
Coroner Harriet Grahame questioned that assessment.
“Did it cross your mind that someone must be feeling pretty bad to come to an emergency department on New Year’s Eve?" she said.
“No, she said she only came because all her friends were out on New Year’s Eve and she wanted some Panadol,” Ms Adams replied.
Ms Adams was also asked to explain a note she left on Ms Williams’ medical records during an earlier visit.
She wrote that Ms Williams was having “recurrent nausea and vomiting” but had refused anti-nausea medication because “she stated it makes her sicker” followed by three exclamation marks.
When asked to explain the three exclamation marks, Ms Adams replied “I don’t know” and that she had never done that before.
Outside court, Ms Williams’ family’s solicitor George Newhouse said her final months were traumatic.
“What was so painful for all of us in the courtroom to listen to was the number of times she actually presented to hospitals, to doctors, asking for care and not getting it,” Mr Newhouse said.
“She became, it appeared from the records we heard today, depressed and miserable from being in constant pain, constant vomiting, without any relief.”
Naomi’s godmother, Aunty Sonia Piper, said the family was not interested in laying blame, but wanted to do whatever they could to improve the treatment of Aboriginal people in hospitals.
“Why wasn't she sent to a specialist somewhere in Sydney or Canberra to really find out what was wrong with her?” Ms Piper asked.
“As an Aboriginal person and an elder in my community, I don’t want to see this happen ever again in my life.”
The inquest continues.