Coronial
NTmental health

Inquest into the death of Pukumani

Deceased

Rita Alimankinni

Demographics

47y, female

Date of death

2021-08-08

Finding date

2025-02-14

Cause of death

acute respiratory failure in the context of known underlying chronic obstructive pulmonary disease, obesity and administration of multiple antipsychotic and sedative medications

AI-generated summary

Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-dose antipsychotic and sedative medications. Critical failures included: (1) prolonged inappropriate stay in ED (62 hours) due to bed block, with seclusion occurring without proper documentation; (2) failure to conduct required respiratory checks during night observations despite policy requirements; (3) failure to implement QID vital observations; (4) incomplete handover missing COPD diagnosis and observation requirements; (5) delayed CPR (7 minutes). Her mental illness overshadowed physical health concerns. Medication change to Aripiprazole, stress, and cannabis use contributed to relapse. Systemic failures in observation protocols, handover processes, and bed capacity were identified. NT Health accepted responsibility and implemented improvements.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryemergency medicineintensive care

Error types

diagnosticcommunicationsystemdelayprocedural

Drugs involved

ketaminepropofolzuclopenthixol decanoatezuclopenthixol acetatearipiprazoleolanzapinehaloperidoldroperidoldiazepamlorazepammidazolamparacetamol

Clinical conditions

schizoaffective disorderschizophreniaacute psychosischronic obstructive pulmonary diseasetype 2 diabeteshypertensionchronic renal diseaseanaemiaobesitymetabolic syndrometardive dyskinesiaacute respiratory failure

Procedures

intubationcardiopulmonary resuscitationcareflight transfer

Contributing factors

  • prolonged inappropriate stay in emergency department due to bed block
  • failure to conduct prescribed respiratory observations during night shift
  • failure to implement QID vital observations
  • incomplete handover from ED to JRU missing COPD diagnosis and observation requirements
  • high doses of multiple antipsychotic and sedative medications
  • medication change to Aripiprazole prior to observation period
  • physical health overshadowed by mental health presentation
  • delayed commencement of CPR (7 minutes)
  • seclusion in oleander room without proper documentation or authorization
  • inadequate staffing and resources in mental health units

Coroner's recommendations

  1. NT Health to conduct review of current arrangements with NDIS service providers to formalise and strengthen arrangements for exchange of information particularly concerning management of client medications
  2. NT Health and CareFlight to jointly consider whether and in what circumstances it is appropriate to use Ketamine when transporting mental health patients to hospital, with any position clearly documented
  3. NT Government and NT Health to prioritise and allocate adequate funding to ensure sufficient beds and mental health staff to remove bed block in mental health inpatient units, increasing from 17 to 30-36 beds per 100,000 population in line with other states and territories
  4. NT Health to develop and deliver mental health specific DETECT training to mental health inpatient staff who provide care to or supervise patients
Full text
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