Woman given 'too many drugs, too little care' before death, coroner finds

Northern Territory Coroner Elisabeth Armitage has found "a string of cascading failures by NT Health staff" contributed to the preventable death of a woman at Alice Springs Hospital in 2023. Judge Armitage concluded Kumanjayi Brogus Ungwanaka received "too many drugs and too little care" after being admitted as an involuntary patient, despite attending the hospital voluntarily. What's next? NT Health has taken full responsibility for the failures but Judge Armitage said "lessons must be learned" and changes implemented and sustained "to prevent similar deaths in the future". The Northern Territory Coroner has recommended NT Health amend its rapid tranquillisation policies following the death of a 34-year-old woman at Alice Springs Hospital where she received "too many drugs and too little care". In handing down her findings today, Coroner Elisabeth Armitage said Hermannsburg mother-of-three Kumanjayi Brogus Ungwanaka had voluntarily attended the hospital seeking help during a psychotic episode in 2023. But Judge Armitage found the Western Arrernte woman was admitted as an involuntary patient anyway before being repeatedly sedated and was ultimately unable to be revived. She concluded that "a string of cascading failures by NT Health staff contributed her death". "These included failures in communication and documentation between medical staff, a failure to document and reconcile her medicine, over-sedation that was not warranted by her presentation, a failure to properly observe and monitor her when she was sedated, a failure to properly consider her co-morbidities and failures by multiple staff to follow hospital policies," she said. "These were the failings of individuals working in a system which permitted mistakes to occur and in a system which did not identify the mistakes or rectify them in time to save her life." In total, Judge Armitage made seven recommendations to NT Health, including that the department amend all relevant training and policies on rapid tranquillisation for use in in-patient units to reflect best practice. She said rapid tranquillisation should only be used as a last resort and only administered with the express approval of a consultant psychiatrist. Judge Armitage also recommended that the type and frequency of nursing observations and the use of physical monitoring devices be mandated along with regular auditing to ensure compliance with the policy. "Kumanjayi was given too many drugs and too little care and this fatal combination caused her death," she said. "With a proper level of care her death would have been prevented." [Image text:] AMP Chirag Ja sAngels 23 08