The Hospital Group Manager for the region which takes in Tumut has broken down in tears and said she wanted to improve relations between Aboriginal people and the health service on the final day of the inquest in the death of Tumut woman Naomi Williams on Friday.
This second phase of the inquest was held on Wednesday, Thursday and Friday last week at Lidcombe Coroners Court in Sydney.
The inquest’s findings will be handed down on July 3.
Ms Williams, a 27-year-old Wiradjuri woman, and her unborn child, died from sepsis in Tumut on January 1, 2016.
She had presented to Tumut District Hospital 18 times in the six months leading up to her death.
Hospital Group Manager Maria Roche said there was a gap in liaison services provided by Aboriginal health workers, who are not employed 24 hours a day.
The Williams family, through their lawyer, presented ideas to Ms Roche about improving the relationship between the Aboriginal community and the health service, and improving the delivery of health care to Aboriginal people.
Ms Roche agreed that this was what was needed, and started crying.
“I’m sorry and I want it to change,” she said to Ms Williams’ family and expressed her condolences to them.
“I welcome the suggestions you put forward here. I really honestly welcome them.”
She previously said she hadn’t been aware of the amount of times Ms Williams had presented to the hospital.
At the inquest on Thursday, Professor Yin Paradies claimed that hospitals suffered from implicit racial bias that meant Indigenous patients received worse levels of care.
“There is a strong correlation between treatment and Aboriginality,” Paradies said.
“There is evidence of stereotyping Indigenous people as more likely to use drugs and alcohol and so that sort of stereotype is very likely to be present in the minds of many Australians, given its pervasiveness,” he said.
Also on Thursday, microbiology expert Dr David Anderson said the antibiotics that could have been used to treat Ms Williams would have been available at a hospital like Tumut, but conceded there was five per cent risk that they would not have saved her.
Ms Williams mother Sharon Williams, speaking after the inquest, described Naomi as an outgoing child, who was involved in community activities from an early age. She loved movies, music and writing poetry and she painted Aboriginal art.
After finishing school Naomi completed a business administration traineeship and worked for Yurauna Centre, as well as relief work at Toora Women’s Refuge.
In Tumut she became qualified as a disability support worker and worked at Valmar with disabled adults, “and her clients loved her”.
“At the time of her death my daughter was a beautiful, 27-year- old woman, passionate about social justice, excited about being pregnant with her first child, and she was highly respected for the strong, hardworking Wiradjuri woman she was,” Ms Williams said.
“My heart was shattered when Naomi passed away. I lost my beloved only daughter and grandson. But I was not alone in my heartbreak. The Aboriginal community at Tumut / Brungle is very close and they suffered too. But Naomi also has a loving family across the country and even overseas. And so, there are many who felt and continue to feel a deep sense of loss with Naomi taken from their lives so suddenly and unnecessarily.
“My daughter, like most of us here was an Australian citizen with rights to appropriate healthcare. But the system let my daughter down. I know that, she knew that and our family know that. She was desperate for help, but her pleas were not heard by the health service in Tumut.
Sharon Williams said her daughter was sick for a long time, but was seemingly invisible to the health system.
“She felt the system didn’t value her as a person and she felt the system didn’t believe her,” Sharon Williams said.
“Even after Naomi’s death, the family was treated with contempt as the hospital showed little respect for our community, our knowledge, and our culture as First Nations people of the country on which their services have been built. Family and community is at the core of our culture.
“At the time of Naomi’s death our grieving community was treated with no respect or compassion. Our cultural protocols were not considered or followed, and no care was taken to ensure that our final moments of goodbye were treated with dignity.
“We felt zero empathy from the staff at Tumut Hospital and we feel that they displayed little throughout this inquest.”
She called for better community consultation, open dialogue, transparency, communication and a culturally safe health service for Indigenous people to come to in times of need.
She urged the health department “to look past the stereotypes and treat Indigenous people in relation to individual health issues, and with respect.
“Naomi’s story is not an isolated experience, there is a wealth of literature and research to support this shameful reality,” she said.
“Racism, discrimination and culturally unsafe practice is a common reality for Aboriginal people across every sector in this country. My daughter and my grandson are gone, but our people are here forever and we must be seen.
“If I could ask the staff at Tumut Hospital and all those in this courtroom one thing, it would be think deeply about the following: How would you feel if your own daughter had received the same treatment leading to January 1 2016? How would feel if you were treated as if your health concerns were not taken seriously? How would you feel if your daughter or son had died the same way as Naomi? And how far would you go to find truth and justice, as if it were something that might give you an ounce of peace?
Sharon said she did not want her daughter to have died in vain.
“Her life meant the world to us, and our worlds have been forever changed. We hope that her death can save others from the same tragedy she met,” she said.
Ms William’s partner and father of her unborn child Michael Lampe also spoke at the inquest.
“It’s just three years ago I was celebrating Christmas in 2015 with Naomi. Life was almost perfect,” he said.
“We had the birth of our beautiful baby boy to look forward to, I was working a decent job, we were going to move closer to Naomi’s mother Sharon. We talked about getting married and then eventually moving closer to my daughter down the coast; the dream life Naomi and I wanted was starting to come together we knew where in life we wanted to be. It really was a dream come true.
“That dream was shattered in an instant on New Year’s Day when I watched the love of my life and my baby die in front of my eyes.”
He described Naomi as always happy, and one of the most honest people he had met.
They would spend time together at the Tumut River, at Blowering Dam, or simply talk for hours.
He disputed prior evidence given by Tumut Hospital staff that Naomi looked well when they saw her.
“That’s all well and good but I want you all to know that I will forever be haunted by the pain and suffering that I saw Nay go through before and after she went to Tumut Hospital on the first of January 2016,” Mr Lampe said.
“Nay was begging for help. When I look back and read the text messages that she sent that night – asking for help with her pain – it makes me sick to my stomach.”
He noted that the day she died was not the first time she’d gone to Tumut Hospital asking for help.
She’d gone there time and again for her nausea during the time she was pregnant, Mr Lampe said.
“She would come home and tell me how tired she was of just being ignored – just being turned away. She felt like nobody there was listening to her.
“One thing I want to get out of this Inquest is for the people at the hospital to learn from all this, from Nay’s death and the death of my baby boy. That way I hope it will never happen again.”
Mr Lampe said his life, and many others, would never be the same following Naomi’s death.
“I fear I will never recover from the pain of having Nay and our baby ripped from my life and I know that the Brungle community will never be the same,” he said.
“Also don’t forget the disabled people who loved her too.”