Inquest into the death of Naomi Williams

27y · Female·Septicaemia secondary to Neisseria meningitides infection

Naomi Williams, a 27-year-old Wiradjuri woman, died from meningococcal septicaemia on 1 January 2016. She presented to Tumut Hospital in the early hours with generalised aches and pains while pregnant. Despite vital signs concerning for infection (tachycardia 120bpm, hypotension 90/50mmHg), she was discharged after 34 minutes with only paracetamol, without medical review, proper pain assessment, or fetal examination. Prior to this, she had made 18+ presentations over 7 months with vomiting, abdominal pain and dehydration, but received symptomatic treatment only—no gastroenterology referral or specialist escalation despite expert opinion that this was warranted. Her low expectations of care, shaped by feeling stereotyped as a drug user and unheard, likely contributed to delayed re-presentation after discharge. Had she been observed longer, reviewed by a doctor, and had prior specialist investigation occurred, meningococcal sepsis might have been detected and treated earlier with antibiotics.