Inquest into the death of Naomi Smith

Contributing factors

• Morbid obesity (150kg)
• Immobilisation during multiple restraint episodes across police, corrections and health services
• Lack of early forensic mental health team involvement
• Absence of multi-agency coordination
• Limited resources in Alice Springs for complex psychiatric cases
• Repeated involuntary admissions and restraint chair use
• Sedation and intubation for transport
• Smoking history

Coroner's recommendations

1. That the Top End Health Service do all things necessary to ensure that the Forensic Mental Health Team provides appropriate service to Central Australia so as to enable early intervention for complex cases.
2. That a multi-agency forum be established that includes a wide range of agencies (including Health, Ambulance, Police and Corrections) so as to enable a proactive and clear multi-agency response to complex cases.
3. A review of the availability and role of forensic mental health services in the Northern Territory should be undertaken to ensure equitable service delivery across the Territory.
4. Consideration should be given to whether a unified Forensic Mental Health Service would improve service delivery, quality and safety.
5. Clarification of governance of clients from Alice Springs being treated by Forensic Mental Health Service with a specified service model.
6. Amendment to Standard Operating Procedures for Alice Springs and Darwin Correctional Centres regarding use of emergency restraint chairs to include discussion of DVT risk factors and procedures for identifying symptoms.
7. Amendment to training materials for Corrections Officers in the use of emergency restraint chairs to include training about material health risk factors including DVT.