Inquest into the death of Naomi Williams

Contributing factors

• Failure to escalate care despite multiple presentations with same symptoms over 7 months
• No medical officer review at final presentation despite abnormal vital signs and pregnancy
• Inadequate assessment of generalised pain in pregnant patient
• No fetal assessment despite 6-month pregnancy
• No specialist (gastroenterology or obstetric) referral for complex, recurrent symptoms
• Hospital notes not reviewed at final presentation
• High-risk pregnancy status not flagged in system despite documented assessment 2 weeks prior
• Lack of investigation into causes of recurrent vomiting and abdominal pain
• Brief 34-minute ED stay insufficient for observation and diagnosis
• Implicit racial bias and stereotyping as drug user affecting care quality
• Patient low expectations of care shaped by prior dismissive treatment
• No Aboriginal Liaison Officer involvement despite multiple presentations

Coroner's recommendations

1. Provide training to all staff about safety alerts (re-presentation calls for medical review, high-risk pregnancy flags) and implement consistent alert implementation methods
2. Implement Nurse Directed Emergency Care (NDEC) policy as a matter of urgency
3. Strengthen Aboriginal Health Liaison Worker program by ensuring 24-hour availability and ensuring staff know that NSW Health Policy Notification/referral of Aboriginal Inpatients applies to ED presentations as well as admissions
4. Adopt targets within MLHD for employment and retention of Indigenous health care professionals at least equivalent to proportion of Indigenous residents in local area
5. Audit 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
6. Identify other assessment tools to measure existence of implicit bias in health care provision and make such tools available to Tumut Hospital
7. Establish targets for proportionate representation of Indigenous people (by population and no fewer than two) on Local Health Advisory Committee and MLHD Board
8. Establish ongoing consultation process with HEAL Mawang Group to develop local model for culturally safe health care in line with Hunter New England Health initiatives
9. Seek immediate consultation with Hunter New England Health regarding strategies for developing culturally appropriate care