Mum sedated four times by medics before overdose death
Abe Maddison |
A mother of three seeking treatment for schizophrenia was sedated four times by medical staff before she died from a drug overdose, an inquest has been told.
NT Coroner Elisabeth Armitage is inquiring into the death of Kumunjayi Brogus, 34, on November 23, 2023.
Counsel assisting Sandra Wendlandt said Ms Brogus was “in the grip of a psychotic episode” in the days before she died in Alice Springs Hospital.
“It was where she wanted to go, to get better,” she said.
“She did the right thing, along with her family, to … get medical help so that she could feel better.”
Ms Brogus had attended the Ntaria health clinic at Hermannsburg community, 125km west of Alice Springs, on November 18 and received a depot injection for her schizophrenia, after missing four months of injections.
She returned repeatedly in the following days and indicated she wanted to go to hospital.
Despite this, clinic doctor Sally Simpson had completed a form on November 23 for her to be admitted as an involuntary patient.
“In my experience, you cannot transfer someone to a hospital by ambulance or the retrieval services will not accept them or take them unless they are on a Form Nine,” Dr Simpson told the court.
“I wasn’t keen on putting her on a Form Nine because she was co-operative and she wanted to go.”
She described Ms Brogus as “pleasantly psychotic”.
“She was lovely. She was delightful. She was talking about Jesus,” she said.
Ms Wendlandt told the court Ms Brogus’ condition had deteriorated on November 23 and she was given a sedative and an anti-psychotic.
Later in the day, she was given a ketamine infusion because it was decided “it was the best way to get to hospital safely”.
After arriving at hospital, Mr Brogus was given more sedatives because the ketamine had started to wear off.
She was later transferred to the mental health unit and on arrival “it appears there was discord between some staff which may have affected the quality of the handover”, Ms Wendlandt said.
“It appears the medical chart did not travel with Kumanjayi to the MHU, that her medication history was not uploaded to electronic systems and the handover was clearly fractured,” she said.
“There is a question about the prescribing of further medication … how it was recorded, and how it was administered.”
Ms Brogus was put on a mattress near a nurses’ window so she could be monitored.
At 12.17am the next day, a nurse noted she could no longer hear Ms Brogus snoring and attempts to resuscitate her failed.
“She was given so many drugs for sleeping that it caused her to stop breathing,” Ms Wendlandt said.
“It would seem this all happened because of a cascading set of communication failures between health staff and health services, an absence of medical reconciliation, and haphazard application of health policies, especially policies to ensure people who are sedated are closely monitored”.
Sedation safety was “at the centre of this inquest”, she said.
Judge Armitage said she had noted Ms Brogus’ family “cared deeply for Kumanjayi, and were gentle and kind with her”.
“They listened to the doctors, and they worked hard with the doctors to do the best they could in caring for her,” she said.
The inquest continues.
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