Kumanjayi Brogus Ungwanaka, a 34-year-old mother diagnosed with schizophrenia, died in Alice Springs Hospital on November 22, 2023, just hours after being admitted after travelling from her remote community.
Following her death, she is referred to as Kumanjayi for cultural reasons.
Kumanjayi knew she was ill and wanted to go to Ward 1 to be cared for and to get better, Northern Territory Coroner Elisabeth Armitage said in her findings released on Monday.
"Kumanjayi was given too many drugs and too little care," the coroner said.
"This fatal combination caused her death."
The "string of cascading failures" by NT Health staff included failing to document and reconcile her medicine, over-sedation and a failure to monitor her when she was sedated.
Under heavy sedation, Kumanjayi's airways obstructed, she could not breathe effectively and her prolonged low oxygen levels caused her death, Judge Armitage found.
A medicine review calculated Kumanjayi had been given 198 per cent of the recommended maximum dose of antipsychotics.
Rebecca Schultz, executive director of the Central Australia Regional Health Service, conceded Kumanjayi's death was "entirely preventable" and NT Health took full responsibility for the failings, the coroner reported.
"I acknowledge that it must now be very hard for Kumanjayi's family to trust the Northern Territory health system," Judge Armitage said.
She referred to "disturbing similarities" to a case in which a woman died in Alice Springs medical care in 2021, prompting coronial recommendations, including regular checks on patients under sedation.
"Specifically, if appropriate respiratory checks had been conducted on Kumanjayi, her deterioration would have been detected and her death prevented."
Judge Armitage recommended the NT Health Department establish a senior executive committee to consider, track and implement coronial recommendations.
She also recommended the NT government modernise the mental health legislation for the territory by finalising a new Mental Health Act within the next year, given the extensive consultation and drafting already done.
The health department should also facilitate family members to accompany patients being transported from remote communities to help support the patient, the coroner recommended.
She also called for a full list of administered medicines to accompany admitted patients coming onto wards as an essential part of admission procedures.
It should also be understood that any form of rapid tranquilisation be a last resort administered only with the express approval of the consultant psychiatrist, she said,
Kumanjayi should not have passed away and with appropriate care she should have gone home to her children, the coroner concluded.
"Her passing must not be in vain," she said.
"Lessons must be learned. Changes must be implemented and sustained to prevent similar deaths in the future."
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