Overview of the Case
The Northern Territory’s health department has been charged in connection with the death of a mental health patient who inhaled aerosol at Royal Darwin Hospital. This incident, which occurred in 2022, has led to serious legal consequences for the department.
Aboriginal and Torres Strait Islander readers are advised that this article contains the name of an Indigenous person who has died. The charges against NT Health include three counts of failing to comply with a health and safety duty. It is alleged that the 22-year-old patient, referred to as Ngalarina, was able to access and inhale the contents of an aerosol can while under the department’s care.
Legal Implications
NT WorkSafe has taken action, charging NT Health with these violations. If found guilty, the department could face a fine of up to $4.5 million. In a statement, an NT WorkSafe spokesperson highlighted that the health organization was aware of the risks associated with aerosol cans but failed to prevent the patient from accessing them within the facility.
This tragic event has prompted a thorough investigation into the circumstances surrounding Ngalarina’s death. A 2024 coronial inquest revealed that the patient had purchased the aerosol from the hospital’s pharmacy while under the supervision of a security guard hours before their death.
Circumstances of the Incident
Ngalarina was found unresponsive in a bathroom on a general ward with an empty aerosol can beside them. Despite efforts to resuscitate the patient, they could not be saved. The coroner, Elisabeth Armitage, noted that NT Health admitted there were no clear procedures in place to guide staff in managing mental health patients in general wards. She concluded that Ngalarina’s death was preventable.
The court heard that the 22-year-old was involuntarily admitted to Royal Darwin Hospital less than two weeks before their death by an on-call psychiatry registrar. The registrar documented the patient as having a “behavioural disturbance in context of VSA [volatile substance abuse]”. The admission was deemed necessary to “further assess and contain risk of harm to self and others, misadventure.”
Movement Between Wards
Ngalarina was initially placed in the hospital’s Joan Ridley Unit, a high-risk secure ward for acute psychiatric patients. However, 12 days after their admission, they were moved to a general orthopaedic ward due to COVID-19 protocols. Soon after, they were granted “grounds leave,” allowing them to walk around the hospital under the supervision of a security guard.
The inquest revealed that aerosol cans were freely available for purchase from two publicly accessible pharmacies at the hospital at the time of Ngalarina’s death. Since then, these products have been removed from shelves and are now available behind the counter.
Coroner’s Recommendations
In her findings, Judge Armitage made a sole recommendation for the health department to consider extending the ban on aerosol cans hospital-wide or keeping them securely if medically necessary. This recommendation aims to prevent similar incidents in the future.
NT Health will face the Darwin Local Court tomorrow, where the charges will be addressed. This case highlights the importance of strict protocols and procedures in managing mental health patients, especially in environments where potentially harmful substances are accessible. The outcome of this legal proceeding may set a precedent for how healthcare institutions handle such situations moving forward.
