A CORONIAL inquest into the death of a pregnant Riverina woman has led to a raft of recommended changes to improve hospital treatment of Indigenous Australians.
Wiradjuri woman Naomi Jane Williams, 27, was six months' pregnant when she died of a heart attack in January 2016 after numerous visits to Tumut Hospital.
Before driving to the hospital on New Year's Day, Ms Williams messaged a friend saying "I can barely move" followed by "just my body aching all over".
Ms Williams was given two Panadol before being discharged 34 minutes after arriving.
She died along with her unborn baby boy after a heart attack later that day.
That final visit marked her 18th to Tumut Hospital in about seven months for symptoms including extreme pain, vomiting, and nausea.
An autopsy report later revealed her death was caused by septicaemia, secondary to Neisseria meningitidis infection, a condition usually treatable with antibiotics.
'Many tears shed': Deputy State Coroner
In her findings on Monday at Tumut Court House, Deputy State Coroner Harriet Grahame said Ms Williams likely had reduced expectations of care because of her history of numerous presentations to the emergency department.
"She received brief symptomatic treatment rather than necessary investigation or specialist intervention of underlying causes," Ms Grahame said.
"On the basis of some of the clinical information known and recorded at the presentation, Naomi should have been further investigated," she said.
Ms Grahame said the evidence in this inquest examined the subject of poor outcomes for Aboriginal people in the health sector.
"The fact that Aboriginal people suffer poorer health outcomes across NSW is well established in the policies and literature provided to this court by NSW Health," she said.
"Examining how these issues may have played a role of an individual patient, as Naomi was, in a small community is both fraught and painful for all concerned.
"The transcript of these proceedings would not indicate the many tears shed during this inquest, not only by the family but by employees of the local health district."
The transcript of these proceedings would not indicate the many tears shed during this inquest.Harriet Grahame, Deputy State Coroner
Ms Grahame also spoke about the pain of Ms Williams' death on her family and the community.
"I acknowledge the enormous pain in Naomi's family and friends and I thank them for their courageous attendance and dedicated participation in these difficult proceedings," she said.
"It is clear to the court that their motivation has been twofold.
"They have been dedicated to trying to find out exactly why Naomi died, but they have also been looking for ways to improve health outcomes for other Indigenous patients in their local community.
"In this way, they are honouring Naomi's life and acknowledging her status as an emerging leader of her community."
Of the nine recommendations she made, seven are towards improving hospital treatment of Indigenous people.
These include strengthening the Aboriginal Health Liaison Worker program, boosting the number of Indigenous employees and board members in health, using various tools to monitoring the possibility of racism and ongoing consultation with an Indigenous groups to develop a culturally safe healthcare model.
Ms Grahame also read out statements by Naomi's mother, Sharon.
"At the time of her death, my daughter was a beautiful woman, passionate about social justice ... and she was highly respected for the strong, hard-working Wiradjuri woman she was," the statement reads.
Ms Williams' partner, Michael Lampe, also had his statement read by Ms Grahame: "We talked about getting married.
"The dream Naomi and I wanted was starting to come together ... it was really a dream come true."
Family hopes for changes to health system
Outside the Tumut Court House on Monday, Anita Heiss, representing the Williams family, said that the family hopes the inquest is the catalyst for structural changes in the health system.
"[In] our healing moving forward, we need to believe that lessons have been learnt and that changes will be made to the health system, not only in Tumut but across the country," Ms Heiss said.
"That no patient in desperate need of healthcare is ever turned away, is ever ignored, or is ever dismissed because of their Aboriginal identity.
"That race is never a factor in determining how someone is treated by any health professional.
"We hope that in Nay's [Naomi] death, other lives will be regarded with more respect.
"This inquest has put the health system on notice."
Ms Heiss also paid tribute to Ms Williams, saying she was a "shining light in our lives".
"We fought this battle to honour Nay's life and to ensure that no other family has to go through the trauma that weighed on and will always weigh on Sharon [Naomi's mother] and those who love her," Ms Heiss said.
"Rest in peace now, Naomi.
"Your legacy will live on in your poetry and the purpose you have given us all to make things better for others."
George Newhouse, the lawyer representing the Williams family, said "the NSW health system continues to deny that racism exists within healthcare".
"We must not live in denial about it," Mr Newhouse said.
"We're hopeful and the family are hopeful today that the health service will listen to the coroner's findings, will make changes and will ensure that Aboriginal and Torres Strait Islander people are treated exactly the same as anyone else would expect in the hospital system."
Before the findings were read out in court, the Tumut Aboriginal community held a traditional ceremony outside the courthouse.
A ceremony was also conducted at Bila Park after court proceedings.
'Implicit bias' a focus
The inquest heard extensive evidence over eight days between September last year and March this year.
Evidence included witness statements, medical records, photographs and expert reports.
Deakin University professor Yin Paradies, an expert on racism in health, in March said the hospital's continual referral of Ms Williams to drug and alcohol and mental health treatments, rather than assessing her physical issues, may have been driven by the stereotyping of Indigenous Australians and implicit bias about race.
Mr Paradies described implicit bias as holding an unconscious view of certain groups and associating them with certain characteristics.
Maria Roche, the Tumut Cluster Manager for Murrumbidgee Local Health District, was also called to the witness box in March.
Ms Roche stated that she wanted change and improvement.
She acknowledged that there is a perception in the local community that the hospital is not a safe place for Aboriginal people and that some drive to other hospitals to avoid it.
On Monday, Deputy State Coroner Harriet Grahame said Ms Roche recognised that there is now an opportunity for change.
"This recognition needs to be forged into further and immediate action. I hope this inquest is a step in that process," Ms Grahame said.