In the valleys around Tumut, a small alpine town to Canberra's south, the Monday morning fog is hanging low and the rain is falling.
Outside the local court house, the family and friends of local Wiradjuri woman Naomi Williams are holding a smoking ceremony before they step inside. For them, Monday was a day three years in the making.
On Monday, a NSW coroner made several recommendations to address Indigenous health outcomes in the small town, after the death of Ms Williams.
They included moves to find and weed out systematic bias against Aboriginal people in the local health system, a quota for local Indigenous health care staff and a 24-7 Aboriginal health contact for the hospital.
Naomi William, 27, died of sepsis on New Year's Day, 2016 after being turned away from Tumut Hospital earlier that morning. She was 22 weeks pregnant.
NSW deputy state coroner Harriet Grahame delivered her recommendations to a packed Tumut Court House, telling the court there was a perception in the local community that Tumut Hospital was unsafe for Indigenous people.
Ms Williams had presented to the hospital in the early hours of the morning on January 1, 2016, complaining of pain, but was sent home about 30 minutes after.
Ms Grahame said Ms Williams should have been "further investigated". Ms Williams later returned to hospital in an ambulance after she collapsed at home. She was pronounced dead in hospital at 3:08pm.
She had presented to the hospital at least 15 times in the months before her death.
Ms Grahame said it was clear Ms Williams felt she wasn't being taken seriously by staff at the hospital, even before she was pregnant.
Ms Williams even travelled to Canberra in December for medical care, unhappy with her treatment in Tumut after she presented the complaining of shoulder pain, abdominal pain and nausea.
Emergency department records at Calvary Hospital on December 18 said Tumut staff had dismissed Ms Williams' complaints as "morning sickness".
Ms Grahame said the evidence showed her Ms Williams was unhappy with her level of care at Tumut, was dismissed by staff and this would have had an effect on her returning to hospital earlier on the day she died.
Ms Grahame recommended that local Aboriginal Health Liason Workers were on call 24/7 and hospital staff be made aware of their duty to contact a liaison when Aboriginal patients attend hospital.
She also recommended the audit of "the possibility of implicit bias" against Indigenous people including recording triage statistics of Aboriginal and non-Aboriginal people, discharge against medical advice and triage times.
Ms Grahame also said the local Murrumbidgee Local Health District should consider targets to employ a portion of Indigenous health care professionals at least equivalent to the local Aboriginal population.
This was on top of a recommendation to have no less than two Indigenous people on the Local Health Advisory Committee and the district's board.
She recommended the district consult with New England Health on culturally appropriate care for Indigenous people.
Later, in the rain outside Tumut court, Ms Williams' cousin Anita Heiss said the family was putting the local health system on notice.
"If you're an Aboriginal woman and you know a local Aboriginal woman went to Tumut hospital and was turned away and died a few hours later, would you go to Tumut Hospital?" Professor Heiss said.
The court had earlier heard of Ms Williams' partner, Michael Lampe's heartbreak at her death. They had planned to have their baby boy in Canberra before moving to the coast.
"The dream Naomi and I wanted was starting to come together," Mr Lampe told the inquiry.
In the local health system, Ms Williams was "desperate" and "invisible", the court heard. But to her mother, Sharon Williams, "Nay" was a passionate social advocate on Indigenous issues and a beautiful, strong, hardworking Wiradjuri woman.