Naomi Williams was six months pregnant when she arrived at a hospital in Tumut, NSW, with severe pain during the early hours of New Years Day in 2016.

Fifteen hours after being discharged, given only Panadol and an iceblock, she and her unborn baby had died of meningococcal and sepsis.

It was the 18th time the mother-to-be had presented to Tumut Hospital in seven months. 

Findings of a coronial inquest into the 27-year-old Wiradjuri woman’s death, released on Monday, found Ms Williams was treated differently by health professionals because she was Indigenous.

The lawyer representing Ms Williams’ family, George Newhouse, told reporters on Monday that he was hopeful the Coroner’s findings would lead to a “better future”. 

“The findings of this inquest indicate that she had lowered her expectations of the care she would get from the hospital because of the way she was treated,” he said.

“The coroner also found that Naomi should have received further examination on the night she passed away.”

Before her death, Ms Williams was a disability support worker who was “loved” by her clients, passionate about social justice and excited to welcome her first child into the world, her family said.

“Naomi, like most of us here, was an Australian citizen with rights to appropriate health care. But the system let her down,” Ms William’s cousin Anita Heiss, representing the family, said following the findings hearing.

“The treatment Naomi received from Tumut Hospital was way beneath any acceptable standard.

“This story will never have an ending for us.”

The inquest, which began in Gundagai near Tumut in September 2018, examined whether the care Ms Williams received was of an acceptable standard and the extent to which systematic failures contributed to her death. 

Dr Heiss said Ms Williams had felt “invisible to the health system” after making repeated visits to the hospital seeking care and added that local Indigenous women were now hesitant to go to the hospital. 

“The reality is if Naomi had presented to Tumut hospital as a non-Indigenous person … her treatment would have been better,” Dr Heiss added.

The family said they were appreciative of recommendations aimed at reducing racial bias in medical settings and fully expected the key findings to be implemented at Tumut hospital.

“They [the inquest findings] are never going to bring Nay back, so the whole goal of this process is to ensure there is structural change,” Dr Heiss said.

More to come