A pregnant woman and her unborn baby died just hours after she was sent home from hospital with painkillers and an iceblock, an inquest heard.
Naomi Williams, 27, was six months pregnant when she went to the hospital in the early morning hours of New Year’s Day complaining of severe pain.
The Aboriginal woman was treated by two A&E nurses who gave her Panadol – a medication used to treat pain and fever – and an iceblock, and then prematurely discharged her within 34 minutes without calling for a doctor, the inquest heard.
Just 15 hours later, Ms Williams, a disability support worker whose pregnancy had been assessed as high risk, and her foetus were both dead after contracting meningococcal and sepsis.
For hours she had writhed in pain at home before collapsing about 1.30pm on January 1.
A coroner found that the mum-to-be had received inadequate care at the hospital in Tumut in rural Australia.
It was her 18th visit to Tumut Hospital in the months before her death.
She was never referred to an obstetrician or a gut specialist despite consistently reporting nausea and vomiting before and after falling pregnant, 7 News reported.
Coroner Harriet Grahame found that Ms Williams should have received further medical treatment on the day she died, SBS News reported.
A lack of treatment during earlier visits likely led to her having “reduced expectations of care” Ms Grahame added.
She also said the number of times Ms Williams had been to hospital was “deeply troubling”.
The coroner said: “It could not have been known by the nurse and the midwife at the presentation that Naomi was suffering from a bacterial infection, which was life-threatening.
“It was not known that she had high complex needs because her hospital notes were not read at the presentation.
“It was not known that she had been assessed with a high-risk pregnancy, about two weeks earlier, because that information had not been flagged.”
But the nurses’ failure to call in a doctor, check Ms Williams’ history or question why a pregnant woman would attend the hospital for Panadol hadn’t helped.
Ms Grahame said: “At the very least, a doctor should have been contacted by telephone for advice and management.
“It is most likely that her experience of care in the early hours of that morning was a factor in her delayed representation later that day.
After the hearing, Ms Williams’ cousin, Anita Heiss, told reporters: “Naomi, like most of us here, was an Australian citizen with rights to appropriate health care.
“But the system let her down.
“The treatment Naomi received from Tumut Hospital was way beneath any acceptable standard.
“This story will never have an ending for us.”
Ms Heiss said her cousin had felt “invisible” to the healthcare system, adding: “The reality is if Naomi had presented to Tumut hospital as a non-Indigenous person … her treatment would have been better.”
Ms Williams’ family was pleased to see the coroner’s recommendations, which included initiatives aimed at reducing racial bias in hospitals.
George Newhouse, a lawyer for Ms Williams’ family, said: “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.
“The coroner also found that Naomi should have received further examination on the night she passed away.”
He hoped the findings would lead to a “better future”.