Pukumani Alimankinni inquest: Family of woman who died while sectioned at RDH remember Jorrijorringa

The family of a woman who died while a sectioned mental health patient at RDH have paid tribute to their beloved ‘kookaburra’, saying they ‘hope that this never happens again to anybody’.

The family of a Tiwi woman who died after receiving a cocktail of drugs while a sectioned patient at Royal Darwin Hospital has paid a heartfelt tribute to the woman they knew as Jorrijorringa, or kookaburra.

Territory Coroner Elisabeth Armitage this week held an inquest in the Darwin Local Court into Pukumani Alimankinni’s death in the Joan Ridley Unit in August 2021.

Before adjourning the hearing for further evidence to be heard at a later date, Ms Alimankinni’s family played the court a recording of the Tiwi translation of the Kookaburra song.

Jorrijorringa, which means blue winged Kookaburra in Tiwi, was Ms Alimankinni’s childhood nickname and members of her family wept as they listened from the front row on Thursday.

In a statement, Ms Alimankinni’s family said every time the children see a kookaburra, they sing that song.

Pukumani Alimankinni's cousin-sister Nicole Intalui (centre) with relatives Mary Ferber-Tomlins (left) and Celvester Munkanome (right) outside court on Thursday. Picture: Jason Walls

“When the song was sung, Pukumani always used to say ‘That’s me! That’s my name, Jorrijorringa’,” they said.

Her sister Stellastina Munkanome told Ms Armitage “We loved Pukamani and miss her so much, we hope that this never happens again to anybody”.

In response, Ms Armitage said she could see that Ms Alimankinni was “very loved by her family” and thanked them for participating in the inquest.

“The family have done everything they can to ensure that we learn from Pukumani’s passing and that we don’t make the same mistakes again,” she said.

“I haven’t had an opportunity to go very often to Tiwi but sometimes I’ve been there and sometimes I’ve been down at the shop and the joyfulness of the singing and the community is very evident to any visitor,” she said.

Pukumani Alimankinni.

“I’m sorry that Pukumani is not with you anymore to enjoy that but I can imagine her singing and laughing and being part of the community.”

Speaking outside court, Ms Alimankinni’s cousin-sister Nicole Intalui said she hoped the inquest would mean no other families had to experience such a loss.

“She was a very loved family member of ours, at times she was always funny and we are very sadly, deeply, deeply sorry that this happened to her,” she said.

“We didn’t expect this to happen to one of our own family members and it hurts deeply.”.

NT has double the national mental health burden, only half the beds

The NT has double the mental health burden of every other Australian jurisdiction with only about have as many beds available for its most acutely unwell residents.

NT Chief Psychiatrist David Mitchell revealed the shortfall on Thursday at an inquest into the death of Pukumani Alimankinni, who died at Royal Darwin Hospital in 2021.

The court previously heard Ms Alimankinni had fallen asleep in the Joan Ridley Unit after being administered with a cocktail of sedatives and other drugs when she stopped breathing.

Prof Mitchell told the court the NT had about 17 beds per 100,000 residents compared with more than 30 in other jurisdictions, describing it as a “terrible narrative”.

He said mental health accounted for about 14 per cent of the Territory’s total health burden, compared with seven per cent elsewhere.

“These are well known facts and this has been the case for years,” he said.

“I don’t say this to be someone who complains because I’m truly someone that’s prospective and looks forward to a solution, I say this because I think the public needs to be aware of the internal stressors that our front line workers experience day to day.

“Leadership at all levels, at my level and above me and below me, we need to be working towards the solutions and we need to be advocating to all levels of government, to the commonwealth and all levels of government, that this is a really important issue.”

Prof Mitchell said the Territory would be judged by “the way we treat the most vulnerable members of our community”.

Prof Mitchell said RDH would need an extra 10 beds just to deal with running the hospital at 100 per cent capacity. Picture: Floss Adams

“People with a mental health issue, people from remote Aboriginal communities, are some of the most vulnerable people in our Australian community and we are judged by the way we treat them.”

Prof Mitchell said RDH’s JRU and Cowdy mental health wards had 31 beds and would need another 10-15 “just to keep even” when the hospital was overwhelmed by emergencies and natural disasters.

“For (RHD) we would need an extra 10 beds just to deal with running the hospital at 100 per cent capacity and we might need extra again — it would be in the vicinity of 50 beds,” he said.

But he said even with more beds coming online, additional funding would be required for staffing which was “the most expensive part of running a hospital”.

“You can build the building and you can build beds but you need doctors, you need nurses, you need Aboriginal health workers, allied health.”

“This is a complex and difficult problem because we’re in a service where we’re actually finding it difficult to retain staff and that’s the issue we’ve got nationally, it’s very hard to retain staff, there’s a worldwide global crisis of health staff.”

The inquest continues.

Nurses waited seven minutes to start CPR on sedated involuntary patient

Staff at Darwin’s acute mental health unit failed to commence CPR on a sectioned patient for seven minutes after noticing her appear to stop breathing while on a cocktail of sedatives and other drugs, a court has heard.

On Tuesday, Territory Coroner Elisabeth Armitage commenced an inquest in the Darwin Local Court into Pukumani Alimankinni’s death at the Royal Darwin Hospital’s Joan Ridley Unit in August 2021.

Counsel assisting Beth Wild told the court Ms Alimankinni had been medicated for mental illness since 1998 and diagnosed with schizophrenia in 2007 before being designated an involuntary inpatient.

As a result, on August 3, 2022 the Tiwi Islander woman was administered ketamine and flown from Wurrumiyanga to RDH where she was allocated an urgent bed at the JRU.

But after spending two full days and nights “under the bright lights of the emergency department”, Ms Wild said there were still no beds available and Ms Alimankinni was again sedated “due to her ongoing disturbed behaviour”.

She said Ms Alimankinni was administered with five different kinds of antipsychotics and three different kinds of benzodiazepines before she was finally admitted to the JRU on August 6.

On August 7, clinical staff noted she “remained irritable and disorganised” before falling asleep on a beanbag and was left to sleep after three different nurses tried and failed to rouse her.

“In the nine hours of (CCTV) footage that follows, there is no further contact between any of the nurses on shift and Pukumani,” Ms Wild said.

She said despite a requirement that they do a “face-to-face” respiratory check every 15 minutes, the nurses instead monitored her via CCTV.

At 5.52am, Ms Wild said one of the nurses finally decided to go and physically check on Ms Alimankinni and “couldn’t see her chest moving”.

“The CCTV footage reveals the non-commencement of CPR for seven minutes,” she said.

“It is commenced but then ceased again prior to the arrival of the rapid response team, who then recommence the CPR. It is unsuccessful. Pukumani is pronounced dead at 6:18am.”

Ms Wild said the failure to monitor Ms Alimankinni, as well as the unexplained delay in the commencement of CPR, had been identified as “root causes” in her death, while the Health Department agreed it was preventable.

“NT Health takes full responsibility for the shortcomings in the care that was provided to Pukumani and is committed to ensuring that systemic improvements are made in response to Pukumani’s death,” the department’s institutional response reads.

The inquest continues.

Originally published as Pukumani Alimankinni inquest: Family of woman who died while sectioned at RDH remember Jorrijorringa