Deceased
Marrianne Fire Tikalaru Munkara
Demographics
45y, female
Date of death
2015-11-11
Finding date
2016-09-02
Cause of death
Bronchiectasis
AI-generated summary
A 45-year-old Aboriginal woman with severe bronchiectasis, COPD, and cor pulmonale died at a sobering-up shelter after police protective custody. She had 15 hospital admissions in 2015 for acute exacerbations related to medication non-compliance associated with alcohol use. Police failed to identify her during the custody episode, missing a critical health alert documenting her at-risk status. Crucially, she met the trigger criteria (three protective custody episodes within two months) for mandatory alcohol treatment assessment under NT legislation, but this was never initiated due to systemic police recording failures. The coroner found the death not directly preventable by police or shelter actions, but identified serious system failures: police non-compliance with legislation requiring protective custody recording, lack of searchable databases for custody episodes, failure to establish identity and check alerts, and inadequate handover procedures between police and shelter staff. Key clinical lessons include the importance of functional systems for identifying at-risk patients in custody, ensuring mandatory treatment thresholds are met, and robust inter-agency handover protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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