Health system changes ongoing following inquest

Talea Bulger speaking outside of the Gundagai Court in 2018 during the inquest into the death of her close friend Naomi Williams.

It has been one year since the inquest into the death of Wiradjuri woman Naomi Williams concluded, and representatives from Ms William’s family are continuing to work with the Murrumbidgee Local Health District (MLHD) to make sure the recommendations are implemented.

Ms Williams was 27-years-old and 22 weeks pregnant when she died of treatable septicaemia at Tumut Hospital on January 1, 2016. Williams presented to Tumut Hospital 18 times in the seven months prior to her death, complaining of pain, vomiting and nausea. Just 15 hours before she passed away, she was discharged from hospital after being given a Panadol tablet in the early hours of the morning.

An inquest into her death began in September 2018, with further evidence taken in March 2019, aiming to uncover whether her previous treatment at Tumut Hospital may have lowered her expectations of care and influenced her decision not to return to the hospital in the daylight hours of January 1 when her symptoms worsened.

Coroner Harriet Grahame concluded that Ms Williams felt “unheard” at Tumut Hospital and made nine recommendations to the MLHD, seven of which pertain to how they care for their Indigenous patients.

George Newhouse, lawyer for the Williams family, said that the recommendations made by the NSW Deputy State Coroner were “profound and far reaching”, and that Murrumbidgee LHD “appear to be taking the recommendations seriously.”

“They are in the process of making changes to address the recommendations within Murrumbidgee Health,” Mr Newhouse said.

“Representatives from Naomi’s family are continuing to work with Murrumbidgee Health on making sure that the recommendations are implemented properly.”

Meetings have taken place between Ms William’s family and the Executive of the MLHD, and Mr Newhouse said this has involved “working on building better relationships between the Aboriginal community and the local health service, having honest and open conversations, and them looking at ways of addressing the issues that arise.”

Mr Newhouse said it is evident that the MLHD has been reaching out to the local community to encourage Aboriginal community members to take up employment within the health district.

“They discussed strengthening the local health service workforce with recruitment and retention of Aboriginal and Torres Strait Islander staff,” he said.

“There’s been a number of changes including new employment opportunities becoming available for local people who have an interest in working in the health sector with a specific focus on the health and wellbeing of the local Aboriginal and Torres Strait Islander community, as well as school-based traineeships.”

Earlier this year, Ms Williams’ family also met with NSW Health Minister Brad Hazzard who “committed to implementing the recommendations across the board in the NSW health system.”

Mr Newhouse said the family is planning to meet with Mr Hazzard again in September to follow up and make sure that the recommendations are being implemented across the state as well as in the MLHD.

“The family is still grieving the loss of Naomi, however it gives them some comfort in their grief to see that changes are in the wings and that [if] implemented, would hopefully avoid deaths like Naomi’s happening in the future,” Mr Newhouse said.

“It’s not all implemented yet, they’re going to keep working on it, it’s a constant labour of love for them and it requires an ongoing commitment from them which is hard.”

Mr Newhouse said that lawyers for the family are working on complaints about medical professionals and nurses which they expect will be made in the near future, and that “the family are still looking at whether to take civil action against the hospital for Naomi’s death.”

In a statement provided to The Times, the Murrumbidgee Local Health District said it “acknowledges the impact felt by the loss of Naomi Williams to her family and friends and the broader Aboriginal community.”

The health district said it extends its thanks to the Williams family and community for their “ongoing patience and understanding with us” over the past 12 months.

“We hope the changes we are making to our policies, procedures, training and recruitment will contribute positively towards community healing and deliver a better quality of health care to all,” the MLHD said.

“MLHD continues to listen and learn from the family and broader Aboriginal community to implement the Inquest recommendations that strengthens support to Aboriginal people across all the communities we serve.”

When The Times contacted MLHD in March earlier this year about which recommendations it had implemented six months on from the inquest, the health district did not cite any examples. Now, one year since the inquest findings were handed down, the MLHD is able to cite a number of changes they have made and are continuing to make.

The health district said it has appointed two Aboriginal people to the MLHD Board to help guide the strategic direction of the organisation.

“The MLHD 2020-2021 goals focus on Aboriginal Health including building workplace culture that is safe, reliable and effective in care, increasing Aboriginal staffing levels, and building a paediatrics services for Aboriginal children and babies and their families,” the health district said in its statement.

MLHD also said it is seeking ways to improve its connection with Aboriginal people through the Healthy Enriched Aboriginal Living Mawang (Together) Group meetings and the Tumut Local Health Advisory Committee, which advocates for health services in the Tumut area. The MLHD Chief Executive is the health negotiator with the Riverina-Murray Regional Alliance Local Decision Making Ngunggiyalali (Accord).

As per the recommendations, representatives from the MLHD also visited Hunter New England LHD to determine strategies for culturally appropriate care. 

“The District has implemented a Nurse Delegated Emergency Care (NDEC) model at Tumut. This model supports nurses to provide timely, quality care for patients presenting to EDs with less urgent conditions. We continue to explore permanent options for an Aboriginal Health Worker to be on call after hours,” MLHD said.

The MLHD also said it has used the NSW Aboriginal Cultural Assessment Audit tool to review hospital capability and a dashboard has been developed to monitor performance and outcomes, in order to deliver culturally appropriate and safe care.

In terms of Emergency Department presentations, the MLHD says it has introduced an electronic system across all services to alter, monitor and report on health indicators for Aboriginal people, with further training provided in Tumut in the use of Electronic Medical Records.

“MLHD values the relationships with local people and remains committed to listen and be guided by the Williams’ family and local community to make further improvements,” the health district said.