“Bed block” in the Northern Territory (NT) health system led to death of a Tiwi Island mother, a coroner has found, recommending that NT government urgently fund the doubling of mental health beds to address an ongoing crisis.
Following days of sedation in the Royal Darwin Hospital emergency department and high-security Joan Ridley Unit, Pukumani Alimankinni, 47, stopped breathing while sleeping in a bean bag on Aug. 8, 2021.
On Feb. 14, NT Coroner Elisabeth Armitage delivered her findings, following an inquest in April 2024.
Alimankinni died because her mental illness overshadowed her physical illnesses and nurses failed to conduct the required observations, she found.
She was “not a well lady” and had chronic obstructive pulmonary disease, type-2 diabetes, hypertension, chronic renal disease, and anaemia.
In the days before her death, Alimankinni was given “high doses” of varying antipsychotics and sedatives, including ketamine, during a Careflight from Tiwi to Royal Darwin Hospital.
She spent three days in the hospital’s emergency department, because there were no beds available in the mental health unit, and a doctor assessed her as suffering from acute agitated psychosis.
Once transferred to the mental health unit, compulsory 15-minute observations were done via CCTV and when she was found non-responsive, medical teams delayed CPR.
An investigation by NT Health found that in addition to gaps in service provision, handover deficiencies, and the multiple and high doses of antipsychotics and sedatives, Alimankinni died because of the failure by nurses to conduct observations and bed block in the ED.
“NT Health take full responsibility for the shortcomings in the care that was provided to Pukumani,” chief psychiatrist David Mitchell wrote in his institutional response to the inquest.
In her findings, Judge Armitage said she agreed with Mitchell’s summary of the impact of bed block on Alimankinni’s care.
“(Bed block) prevented Pukumani from receiving care in a therapeutic environment,” Mitchell told the inquest.
“The prolonged period in (the ED) environment, lasting days, may have even exacerbated Pukumani’s distress.
“This potentially added to the need for further medication and sedation. The accumulative effect of this was catastrophic.”
The NT has 17 beds per 100,000 people, compared to every other jurisdiction, which has about 30, and the highest being about 36, Mitchell said.
“So we have half the available beds of every other jurisdiction. It’s a terrible narrative. We also have double the mental health burden.”
At a minimum, the NT government should urgently allocate sufficient funding to ensure that the 17 mental health beds for every 100,000 population is increased to 30-36, Judge Armitage recommended.
In a statement, NT Health said it would review the findings and recommendations “and implement actions as appropriate.”
The department said a new mental health inpatient unit under construction at Royal Darwin Hospital was expected to be completed by the end of 2025.
But Judge Armitage said funding for staff to support additional patients was still to be resolved.
“This critical work must continue as we are judged by the way we treat our most vulnerable citizens,” she said.
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