5th August 2019

Culturally Dangerous Governance underlies the Death of Naomi Williams

By DrMJLock

*Media Statement* by Ngiyampaa academic Dr Mark J Lock, Founder of Committix Pty Ltd, Australia’s only Indigenous private research company.

In this traumatic case(1), the CEO of Tumut Hospital’s response was carefully crafted in accord with the technical bureaucratic words of NSW Health Policy on Open Disclosure(2):

“Open disclosure is an individual and health service-level response to incidents of patient harm. It is a process in which healthcare providers communicate with, and support, patients who have been harmed as a result of health care. It is considered an important element of good clinical practice and professional ethics, and is part of effective clinical communication.”(3)

Or, as one insider says about Open Disclosure, it is the “cover your arse” policy.

And that appears to be Murrumbidgee Local Health District’s attitude to First Nations Australians, because it is clear that the views of patients with the highest rate of contact with hospitals, with the greatest health disadvantage, and history of distrust of hospitals, were left out of the development of Open Disclosure policy.

Dr Lock says, “the death of Naomi Williams is a symptom of poor governance of the Tumut hospital and, by extension, reflects poorly on the governance of the NSW Health System”.

So it is right for Lawyer George Newhouse to say, “Naomi’s family will not be in a position to accept any apologies until Tumut Hospital staff show by their conduct that they are taking the culturally safe care of Aboriginal patients seriously and they make real — and permanent — changes to the way that they treat Aboriginal people.”(1)

“Ms Ludford’s words of “deeply sorry” look insincere compared to the bureaucratic lines she used in media statements over the years since Ms Williams’ death in 2016, words like ‘conceded’, ‘failed’, ‘should have been’, and ‘carefully considering’”, said Dr Lock

Dr Lock has demonstrated how the development of Open Disclosure standards (which began when Ken Wyatt was the Director of Aboriginal Health in NSW) in the NSW Health system systematically excluded the cultural voices of Aboriginal people in Open Disclosure policy development.

Dr Lock explains, “Open Disclosure policy began in 2003 and, to this day, has not included any views of First Nations Australians – we are invisible in Open Disclosure policy, a clear sign of institutional racism”

Institutional racism is why the report of the internal investigation(4) in Ms Williams death has reminded behind closed doors.

“In a system that encourages Open Disclosure, why does the internal report on Ms Williams death remain secret?” states Dr Lock

Dr Lock says, “Put it this way, if an alleged criminal conducted their own secret investigation into their alleged victim’s circumstances, and paid the wages of the alleged staff involved in that investigation, and were allegedly supported in doing so by a multi-billion dollar organisation, do you think they would openly disclose wrongdoing?”

Dr Lock’s personal experience with non-Aboriginal health professionals’ attitudes about Open Disclosure are that meetings between hospital staff and patients are behind closed doors and Aboriginal patients are not allowed to have legal representation or advocates present in the conversation. The Open Disclosure process is carefully managed to avoid litigation and to intimidate the patient into staying silent. That’s why there are no publicly available records of Open Disclosure incidents and First Nations Australian, and why our cultural voice is devalued in Open Disclosure research and policy development. Read the full report ‘Australian Open Disclosure – Closed to Cultural Voice’.(5)

“It’s about time staff were held to account, CEOs step-up to take responsibility, and genuine respect shown for Naomi Williams, her family, and the Aboriginal community of Tumut” said Dr Lock.


  1. https://mobile.abc.net.au/news/2019-08-02/naomi-williams-family-apology-rejects-health-district-apology/11377174?pfm=sm
  2. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2014_028.pdf
  3. https://www.safetyandquality.gov.au/publications-and-resources/resource-library/open-disclosure-standard-review-report
  4. https://www.oberonreview.com.au/story/4022661/fatal-decision-to-turn-away-pregnant-woman-defended/
  5. https://committix.com/projects/cultural-voice-and-open-disclosure/