THE local health district has vowed to improve hospital treatment of Indigenous patients following the coronial inquest into the death of Wiradjuri woman Naomi Jane Williams.
Ms Williams, 27, was six months' pregnant when she died on New Year's Day in 2016 despite presenting herself numerous times to Tumut Hospital for extreme physical pain, vomiting, and nausea.
An autopsy report later revealed her death was caused by septicaemia, secondary to Neisseria meningitidis infection, a condition usually treatable with antibiotics.
MLHD CEO Jill Ludford said the health district again extends its sincere condolences to the family and friends of Ms Williams.
"The district has just received the [deputy] coroner's findings and will now carefully review and consider the recommendations made," Ms Ludford said.
"We are committed to making healthcare a more positive experience for our Aboriginal community."
Ms Ludford said Tumut Hospital has already implemented a number of changes, including further cultural awareness and safety training in partnership with the local Aboriginal community to enhance local connections and knowledge.
As well, they have started regular conversations between Aboriginal community representatives and Tumut Hospital managers to identify local priorities.
Aboriginal community representatives have also reportedly been more involved in the Local Health Advisory Committee.
In her findings published on Monday, State Deputy Coroner Harriet Grahame found that implicit racial bias and a lack of emergency care and awareness were major contributing factor to Ms Williams' death.
Ms Grahame said there was a "lack of escalation of care" when Ms Williams presented herself numerous times before her death.
"On the face of the evidence, the sheer number of presentations without a specialist review is deeply troubling," she said.
Ms Grahame said treatment is largely reactive and despite regular contact, there appears to have been a reluctance to take a leading role in Ms Williams' healthcare.
She said there was an opportunity for change and made nine recommendations to the Murrumbidgee Local Health District to improve emergency care for Indigenous patients.
These include ensuring that there are Aboriginal health liaison workers 24 hours a day, adopting targets within the MLHD for employing Indigenous health care professionals, boosting the number of Indigenous committee and board members in health, and using various tools to monitor the possibility of racism.
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The inquest also recommends ongoing consultation with the Healthy Enrichment Aboriginal Living Mawang group to providing culturally safe health care in line with initiatives by Hunter New England Health.
Other recommendations include training staff about safety alerts, such as "re-presentation calls for medical review" and "high-risk pregnancy", and a consistent way of communicating alerts to staff.
Health Minister Brad Hazzard has not yet responded to media queries.
Outside of Tumut Courthouse on Monday after the findings, Ms Williams' best friend Talea Bulger said she has noticed some changes at Tumut Hospital since Ms Williams' death.
"But there's a long way to go," Ms Bulger said.
"Today is the beginning of getting all those changes implemented and acted upon.
"We hope the hospital is listening."
Asked if hospital management has apologised to the family, Ms Bulger said it has not.
However, she said she hopes relations may be improved following the inquest.
George Newhouse, the lawyer representing the Williams family, said implicit racial bias "lies at the heart of the Naomi Williams inquest" and that it has been denied in the health system.
"We must not live in denial about it," Mr Newhouse said.
"We're very hopeful that those findings will lead to a better future."