A nurse who attended Naomi Williams at Tumut hospital on the day she died had not undertaken training necessary to help identify sepsis in pregnant women, and admitted she had not done a full assessment of Williams before allowing her to go home, a coroner’s court heard on Tuesday.

Williams, a 27-year-old Wiradjuri woman who was six months pregnant with her first child, died from sepsis associated with the bacterium Neisseria meningitidis, a serious infection that is treatable with antibiotics.

Williams arrived at the emergency department at 12.19am, was given paracetamol and discharged after 34 minutes. Just 15 hours later she was dead.

Registered nurse and midwife, Julie-Ann Brewis, told the Gundagai coroner’s court she now understood that a higher degree of suspicion of sepsis is required in pregnant women than the general population, and said she now understood that Aboriginal people were at higher risk of sepsis.

But Brewis could not explain why Williams’ temperature was not taken a second time before she was discharged in the early hours of 1 January 2016.

Williams was treated by two nurses who gave evidence on Tuesday: Brewis, and Shirley Adams, a registered nurse with 40 years’ experience.

Williams’ four main vital signs – temperature, pulse, respiration rate and blood pressure – were all recorded as being on the border of a hospital policy guide known as the “yellow zone”. When observations fall into this yellow zone, further action is triggered, such as calling a doctor, or further investigation or observation.

Some of Williams’ vital signs were recorded a second time 15 minutes later, during which time her blood pressure had improved and she was allowed to go home shortly afterwards.

A number of questions about the treatment Williams received were raised by the counsel assisting the coroner, Lesley Whalan SC, and by Maria Gerace, the lawyer representing Williams’ family.

They asked why Williams’ temperature wasn’t taken a second time before she was allowed to go home, why a formal pain assessment wasn’t undertaken and why a better history wasn’t taken.

Williams had been diagnosed with hyperemesis gravidarum, a complication of pregnancy characterised by severe nausea and vomiting. She had presented to Tumut hospital 18 times in seven months with nausea and vomiting, and sometimes diarrhoea and dehydration, but was often sent home after receiving medication and IV fluids.

She was referred multiple times to drug and alcohol and mental health services, which repeatedly found no dependence issues or mental health problems.

Nurse Brewis told the Gundagai court that Williams arrived at the emergency department eating a hydralyte iceblock – a common treatment for nausea - and asking for panadol to help her sleep, saying she had hip pain which she thought was caused by pressure from the baby.

Brewis gave Williams two panadol but took no formal pain assessment. Only “generalised pain” was recorded in the notes.

Counsel assisting the coroner, Lesley Whalan said Williams’ partner, Michael Lampe reported that she had been vomiting that night and complaining of headaches, as well as back pains and spasms. However, both nurses said Williams told them she had not vomited for the previous two days and denied she had a headache.

When asked why Williams would be eating a hydralyte iceblock if she was not suffering from nausea and hadn’t been sick for two days, Brewis said: “I don’t know, she just liked to eat ice.”

Brewis told the court that she was aware Williams had been to hospital in Canberra two weeks earlier but couldn’t answer why that hadn’t prompted her to take a more complete history from Williams, to find out which hospital Williams attended, why she went there and what treatment was given.

When Williams’ family lawyer Maria Gerace asked Brewis why she hadn’t taken Williams’ temperature a second time that evening she replied that she was “not sure”.

“Do you accept that you should have?” asked Gerace.

“Yes,” Brewis replied.

Nurse Adams told the court Williams looked well and like she was “blossoming from pregnancy”.

Brewis said Williams told her that “she could sleep now and wanted to go home” when she was discharged.

While Brewis admitted she “probably didn’t do a good assessment of her pain,” she said by Williams’ appearance, she looked to be in “minimal” pain. Brewis told the court she felt she had developed a rapport with Williams during the visit and that when Williams left, she said to Brewis, “Thank you for being so nice”. No physical examination was undertaken by the staff.

The inquest continues in Gundagai on Wednesday, when the court will hear evidence from Williams’ general practitioner.