Ngalarina’s deodorant sniffing death at Royal Darwin Hospital preventable, coroner hears

The court heard Ngalarina was found unconscious next to an empty deodorant can and could not be revived after being involuntarily admitted to Royal Darwin Hospital.

Ngalarina was involuntarily admitted to Royal Darwin Hospital in January following a history of mental health and substance abuse issues.

A young Territorian who died from sniffing deodorant after being sectioned at Royal Darwin Hospital last year was the victim of “a litany of failures”, a court has heard.

NT Coroner Elisabeth Armitage on Tuesday began an inquest into the death of the 24-year-old, referred to in the Darwin Local Court as Ngalarina and by the pronouns they/them.

In her opening statement, counsel assisting Chrissy McConnell said Ngalarina had been involuntarily admitted to the hospital in January following a history of mental health and substance abuse issues.

On January 31, Ms McConnell said doctors approved ground leave for Ngalarina, meaning they could leave the facility while staying within the hospital grounds accompanied by a security guard.

“The security guard who was to accompany Ngalarina for all ground leave was not told of Ngalarina’s history of volatile substance abuse and was of the understanding that his role was confined to monitoring the patient and ensuring that they didn’t run away,” she said.

During one trip through the hospital grounds that afternoon, Ms McConnell said Ngalarina bought two bottles of deodorant and later went for a shower before a different security guard alerted a nurse that he had not heard from them for 10 minutes.

She said the nurse unlocked the door with a pair of scissors and found Ngalarina unconscious on the floor next to an empty deodorant can and they could not be revived.

“Ngalarina’s death has been identified by Dr Luke Butcher who is the institutional representative for the Department of Health as a sentinel event,” she said.

“That is an event where something preventable goes wrong with a patient’s care which causes the serious harm or death of a patient.”

Ngalarina’s mother Averly Wakuranhawuy told the court she “sat there for two days, crying” after she learned of her child’s death.

“I was asking them questions and one doctor said to me ‘He was OK, he was happy on that day’,” she said.

“He asked him where you want to go back to, he said ‘To come back to home where my mum (is)’ and I was thinking ‘What really happened to him?’ because everything was good.”

Ms Wakuranhawuy said she now thought about Ngalarina whenever she walked around her community of Milingimbi where Ngalarina grew up.

“Every time I see the breeze coming in I always think about him because he was my loved one even though he (drove me) crazy,” she said.

“I’m very happy that he’s in a better place now, I don’t need to worry.”

The inquest continues on Wednesday.