A pregnant indigenous woman sent home from a hospital emergency department on the day of her death was inadequately assessed before she died, two experts have told a NSW court.
Naomi Williams, 27, was six months' pregnant when she died of sepsis associated with the meningococcal bacteria immediately after being rushed to Tumut Hospital about 3pm on January 1 in 2016.
She'd presented to the same hospital earlier that day complaining of general aches and pains but was sent home by a midwife without seeing a doctor.
The inquest into her death continued in Sydney on Wednesday after opening in September 2018 in Gundagai.
According to hospital notes, Ms Williams arrived at the emergency department at 12.19am on New Year's Day complaining of aches and pains. Her heart rate was 120 beats per minute while her blood pressure was 90 on 50. She had no recent vomiting.
After being given two Panadol to treat the pain, her blood pressure and heart rate were recorded again at 12.35am at 105bpm and 95 on 52.
Ms Williams was sent home at 12.53am some 34 minutes after first presenting.
Two nursing experts - registered nurses and educators Eunice Gribbin and Jasmin Douglas - told the court they would have had cause for concern and further assessed a patient like Ms Williams.
Ms Douglas said the second set of results were slight improvements on the first but weren't reason enough to discharge a patient.
She'd have conducted further assessments and asked a doctor or midwife to use other diagnostic tools such as a speculum and fetal heart rate monitor.
"They have still not established the cause of the pain," the postgraduate emergency nurse told the inquest.
"It was not appropriate to discharge her then."
Ms Gribbin, who teaches nursing standards of care, said 10 minutes was not enough time to assess whether the Panadol had taken effect and she'd have thought it "mandatory" that any pregnant woman with such symptoms would be seen by a doctor.
The court has previously heard Ms Williams presented to Tumut hospital 18 times in the eight months before her death with similar issues.
"My aunty not only lost her only daughter but her only grandchild," Ms Williams' cousin, Graham Kilby, told reporters outside court on Wednesday.
"I want justice. I need answers. Our family needs closure. We're struggling".
National Justice Project solicitor George Newhouse said the family wanted to get to the bottom of whether race played a role in Ms Williams' care.
"She was sick, she was seeking help but not once (in all her hospital presentations) did she get a referral to a specialist," he said.
"Indigenous people from around Australia complain about discrimination consistently. It's a silent killer and it really needs to be assessed."
The inquest, before deputy state coroner Harriet Grahame, will hear from doctors, a racial discrimination expert and the family later this week.
SOURCE: Channel 9