The deputy state coroner has urged a southern New South Wales health district to look at levels of implicit bias and improve its representation of Indigenous workers following the death of a young pregnant woman.

Key points: A coroner has urged for change in a NSW health district following the death of a young pregnant woman

A coroner has urged for change in a NSW health district following the death of a young pregnant woman Naomi Williams visited Tumut Hospital 20 times in the months before she and her unborn son died

Naomi Williams visited Tumut Hospital 20 times in the months before she and her unborn son died The inquest found that implicit bias and a lack of Indigenous representation can no longer be denied

Naomi Williams, a Wiradjuri woman, was 27 years old and 22 weeks' pregnant with a son when she died of septicaemia at Tumut Hospital in January 2016.

The inquest heard Ms Williams made 20 visits to Tumut Hospital and a number of doctors from nearby medical centres in the seven months before her death.

In handing down her findings in a packed courtroom in Tumut Local Court today, coroner Harriet Grahame said there were clear and ongoing inadequacies in the care Ms Williams received, and that she felt unheard by her doctors and staff at Tumut Hospital.

"Naomi's history of numerous and frequent presentations to the Emergency Department in the months immediately preceding that presentation, where she received brief symptomatic treatment rather than necessary investigation or specialist intervention of underlying causes, likely led to her having reduced expectations of care at this time," Ms Grahame said.

"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 because that information had not been flagged."

Findings won't bring 'shining light' back

Anita Heiss, Ms Williams' cousin, said the family will always be at a loss because they had lost the "shining light" in their lives.

But she said today's findings had confirmed what they already knew.

"Naomi, like most of us here, was an Australian citizen with rights to appropriate healthcare, but the system let her down," Ms Heiss said.

"We know that. She knew that. And now, through this coronial inquest, it has been proven that the treatment Naomi received from Tumut Hospital was way below any acceptable standard.

"She was invisible to the health system.

Friends and family of Naomi Williams leave the Tumut Court House after the inquest findings were handed down. ( ABC Riverina: Melinda Hayter )

"This inquest has put the health system on notice and we hope that in Nay's death, other lives will be regarded with more respect.

"We will be making sure that everything the coroner has recommended is enacted, and we want to see that happen across the country, because the racism that exists here is duplicated, unfortunately — not only in country towns but in urban centres as well.

"All that we can hope for, in a positive way, out of Nay's passing is that real change will come through this inquest."

A traditional smoking ceremony was held outside the Tumut Court House before the inquest findings were handed down. ( ABC News )

George Newhouse, the solicitor for Naomi's mother, Sharon, and her partner, Michael Lampe, said it had taken three years but finally the truth had come out.

"Naomi Williams was in the prime of her life when she passed away," Mr Newhouse said.

"She'd attended hospital 15 times in the months before she passed away without receiving a referral to an expert and the findings of this inquest found she'd lowered her expectations of the care she would get from the hospital because of the way she was treated on each of those times.

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

Implicit bias central to inquest

Of the nine recommendations, seven provided suggestions for the Murrumbidgee Local Health District to review and improve how it provided care for Indigenous patients.

This included looking at levels of implicit bias, improving Indigenous representation among staff, and consulting with the local Indigenous community.

During the inquest, a number of witnesses provided statements to the court of their perceptions of local racism and second-rate care at Tumut Hospital.

Coroner Harriet Grahame travelled to Tumut to deliver the inquest findings. ( ABC Riverina: Melinda Hayter )

One stated that a lot of Aboriginal people felt they could not go to the hospital because they would not get the treatment they needed.

Others spoke of bad experiences or of feeling family members were stereotyped because of their Aboriginality.

Seven of the recommendations handed down by the coroner today related to employing more Indigenous healthcare professionals, increasing representation of Indigenous people on the local health advisory committee and Murrumbidgee Local Health District Board, and improving access to culturally safe and appropriate health care.

"It is important the hospital's workforce is representative, that it entails people at all levels with different types of seniority — that would include nurses and doctors," Ms Grahame said.

"It is important that there is understanding of family commitments, an understanding of racism that Aboriginal people have experienced, in order to produce a culture where there is trust, communication and respect for the Aboriginal workforce."

Mr Newhouse said the implicit bias and racism that existed within the health system could no longer be denied.

"That's what lies at the heart of the Naomi Williams inquest, and we must not live in denial about it," he said.

"We're hopeful that the health service will listen to the findings, will make changes and will ensure that Aboriginal and Torres Strait Islander people are treated exactly as anyone else would expect in the hospital system."

Findings will be carefully considered, official says

In a statement, Murrumbidgee Local Health District chief executive Jill Ludford expressed her sincere condolences to the family and friends of Ms Williams.

Ms Ludford said the coroner's recommendations will now be carefully reviewed and considered.

"We are committed to making healthcare a more positive experience for our Aboriginal community," she said.

"Tumut Hospital has already implemented further cultural awareness and safety training in partnership with the local Aboriginal community to enhance local connections and knowledge.

"Regular conversations between Aboriginal community representatives and Tumut Hospital managers have been introduced as well as involvement of Aboriginal community representatives in the Local Health Advisory Committee."