Ngalarina inquest into hospital chroming death in care reveals Darwin reliance on ‘outlier’ patients

A lawyer has slammed the ‘inadequate’ hospital practice which leaves vulnerable patients in the care of Darwin nurses with no mental health training in their care.

Counsel assisting the coroner Chrissy McConnel said changes at the Royal Darwin Hospital 18 months after a young Territorian’s death were “inadequate” to protect patients and staff alike. Picture: Pema Tamang Pakhrin

Darwin nurses with no mental health training are being asked to care for vulnerable patients and forensic cases under guard, a coronial has heard.

Over a three-day inquest Territory Coroner Elisabeth Armitage heard about the pressures on the hospital system which ultimately resulted in a fatal chroming incident of a 24-year-old involuntary inpatient, known as Ngalarina.

In a frank closing submission last week, counsel assisting the coroner Chrissy McConnel said changes at the Royal Darwin Hospital 18 months after a young Territorian’s death were “inadequate” to protect both patients and staff.

Ngalarina’s mother Averly Wakaranhawuy and aunt Judith Madupinyin pleaded for change to address volatile substance abuse (VSA) and mental health service gaps, saying “we don’t want to lose any more young people in our community”.

Counsel assisting the coroner Chrissy McConnel said changes at the Royal Darwin Hospital 18 months after a young Territorian’s death were “inadequate” to protect patients and staff alike. Picture: David Gray

Ms Armitage heard due to high demand for mental health beds in January 2022, Ngalarina was assigned to an orthopaedic ward as an “outlier” patient.

Despite a history of chroming and self harm, Ngalarina was under the care of nurses who had never heard of the acronym ‘VSA’ before — with one saying at the time she did not know what schizophrenia was.

“(They) were not trained in any way, shape or form, in the treatment and care of mental health patients,” Ms McConnell said.

Top End Mental Health regional executive director Luke Butcher said the Health Department said it had since put the aerosols behind the counter and implemented VSA training, but Ms McConnell said this did not reflect the reality on the wards.

“The evidence of the nurses … did not reflect a sound, confident knowledge of VSA,” she said.

“Neither of those nurses have received any training – whatsoever – in dealing with mental health patients. Nothing.

“It’s been 18 months of general nursing staff dealing with mental health patients without the skills, experience or confidence to do so.

“They are at risk. The patients are at risk.”

While with an assigned hospital guard on January 31, Ngalarina bought two cans of aerosol deodorant from the hospital shop — which unlike all Territory Coles and Woolworths had the products open on the shelves.

After spending 20 minutes alone in a bathroom, Ngalarina was found unconscious on the floor next to an empty deodorant can.

Ms McConnell asked — given the “unsatisfactory” training, poor information sharing, and chronic pressures on the mental health unit — how many more deaths it would take for the health system to step up.

Ngalarina’s family called for better hospital record keeping and information sharing, better communication to families and health clinics and community-based programs about dangers of chroming and mental health education.

Despite investigating the death in care of a queer person and mandatory inpatient, the coroner did not hear evidence from LGBT+ groups or the NT Community Visitor Program, which monitors mental health facilities.

There have been five deaths across from chroming investigated by the Territory coroner since 2008, including for children as young as 12 years old.

Originally published as Ngalarina inquest into hospital chroming death in care reveals Darwin reliance on ‘outlier’ patients