Naomi Williams was sent home from hospital with two panadols. 15 hours later she was dead.

Naomi Williams was six months pregnant with her first baby when she arrived at the local hospital in the small country town of Tumut, NSW, in the early hours of New Year’s Day in 2016.

She’d been vomiting all evening. She had a severe headache, her back kept spasming.

Despite her partner Michael Lampe urging her to go to hospital, the disability worker didn’t want to go. She hated going to hospital and often put it off until she was very sick.

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Naomi had long lost confidence in Tumut hospital staff’s ability to help her, having visited 18 times in the seven months prior with vomiting and nausea, sometimes diarrhoea and dehydration, only to be discharged each time with no relief or explanation of the pain she was suffering. In her 18 visits, she had never been referred to an obstetrician or a gut specialist, instead she was repeatedly referred to mental health or drug and alcohol services – even though Naomi had no history of drug or alcohol problems and the services had already determined she had no dependence issues.

She felt that the hospital staff were ignoring her pleas; they’d already written her off as a drug addict. She kept telling the friends and family who urged her to go to hospital that she “wasn’t getting treated right” and they “wouldn’t find out what was wrong with her”.

This time was no different.

Two emergency nurses quickly looked at her, gave her two Panadols and sent her home. No physical examination was taken, nor a formal pain assessment. Her medical history wasn’t checked and the doctor on duty was not called.

In a little over half an hour, Naomi Williams was once again discharged from hospital with no answers for her ongoing pain.

She returned home, still in pain and still vomiting. As the morning wore on, she deteriorated fast. It got so bad Michael had to help her go to the toilet and shower. At about 1.30pm, Naomi collapsed in the hallway. She couldn’t feel her legs anymore.

An ambulance was called and she was taken back to the hospital but it was too late. Naomi went into the cardiac arrest.

Fifteen hours after she had was sent home from the hospital for the nineteenth time, Naomi Williams and her unborn baby – a son she and Michael had already picked out a name for, Tristan – were declared dead. She was just 27 years old.

An autopsy found that Naomi had died of sepsis, a serious infection but one that is treatable with antibiotics.

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Now a coronial inquest into the Wiradjuri women’s death has concluded that there was implicit bias in the way Naomi was treated by staff at Tumut hospital.

The three-year inquest, which released its findings on Monday, found that Naomi should have received further examination on the day she died and made several recommendations to address the health system’s treatment of Indigenous people.

Harriet Grahame, the deputy state coroner, accepted the two emergency nurses couldn’t have known Naomi had a life-threatening infection that would soon kill her.

But their failure to call in a doctor, look at Naomi’s history or wonder why a pregnant woman would attend hospital on New Year’s Day, solely for Panadol, hadn’t helped.

“Curiosity in a safe environment may have kept Naomi long enough for swift and appropriate intervention when her condition did not improve,” Grahame said.

“At the very least, a doctor should have been contacted by telephone for advice and management.”

“On the face of the evidence, the sheer number of presentations prior to 31 December 2015, without specialist review, is deeply troubling.”

Among nine recommendations, Grahame advised Murrumbidgee Local Health District – the operator of Tumut Hospital – to investigate systematic bias against Indigenous people in the health system, increase representation of Indigenous health care staff and start a 24-7 Aboriginal health contact for the hospital.

For Naomi’s friends and family, and the wider Indigenous community, the coronial inquest findings finally acknowledged what they had known for so long.

George Newhouse of the National Justice Project, which represented the Williams family throughout the coronial inquest, said Naomi’s family feel validated that the coronial inquest recognised that bias impacted the treatment of Naomi.

“They feel they’ve been heard, someone is finally listening,” he told Mamamia, “especially when the coroner acknowledged Naomi’s extremely low expectation the quality of care she would receive from the hospital were justified.”

“It’s extremely difficult for Aboriginal people to seek and obtain vindication, because navigating the system is complex and they feel powerless within it. Ultimately, they really appreciate the findings,” he added.

Newhouse said that the coronial findings were a good start, but if Indigenous people are to feel safe in hospitals, the changes recommended needed to be implemented Australia-wide.

“The coroner has done all Australians a favour by naming one of the factors that contributed to Naomi’s death as implicit bias on the basis of her race,” he said. “If we live in denial, the pain will continue.”

“The findings show bias and unconscious prejudices can kill. If we truly care, we need to all work together and provide a safe place Aboriginal people can get genuine care.”

Academic commentator Anita Heiss said her cousin was a “shining light in our lives” who loved movies, music, painting and writing poetry about the river and her family.

“We are reminded today that Naomi was desperate for help but her pleas were not heard by the health service in Tumut,” she told reporters on Monday.

“Naomi was sick for a very long time and no one listened to her or helped her. She was invisible to the health system. She felt it didn’t value her as a person.”

To the NSW health system Naomi may have been invisible, but to her family Naomi will always be remembered as the strong Wiradjuri woman who passionately advocated for Indigenous issues.

— With AAP.