Coroner blames medication overdose and neglect for psychiatric patient’s death in Alice Springs
A coroner concluded that a 34-year-old woman died in an Alice Springs psychiatric ward after receiving excessive antipsychotic medication and inadequate monitoring.
Kumanjayi Brogus Ungwanaka, a 34-year-old mother with schizophrenia, was admitted to Ward 1 of Alice Springs Hospital and died on November 22, 2023, shortly after arrival from a remote community. The Northern Territory Coroner, Elisabeth Armitage, identified a cascade of errors: failure to document and reconcile her medicines, administration of a double dose of antipsychotics (198 % of the maximum), and insufficient monitoring while she was heavily sedated.
The over-sedation caused airway blockage and prolonged low oxygen levels, which the coroner said caused her death. Rebecca Schultz, executive director of the Central Australia Regional Health Service, acknowledged the death was entirely preventable and that NT Health bears full responsibility. The coroner recommended establishing a senior executive committee to implement coronial recommendations, finalising a new Mental Health Act within a year, allowing family members to accompany patients from remote areas, and ensuring full medication lists accompany admissions. She stressed that rapid tranquilisation should only be used with consultant psychiatrist approval.
Why it matters
The case highlights critical gaps in mental-health care and patient safety that could affect many vulnerable patients.
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