A young Indigenous mental health patient who died sniffing deodorant in a Darwin hospital bathroom was a victim of a series of failings, an inquest has been told.
Ngalarina was involuntarily admitted to Royal Darwin Hospital in January 2022 with a history of schizoaffective disorder, psychosis and volatile substance abuse (VSA).
When Ngalarina was admitted, a COVID-19 outbreak was taking over the hospital and beds were scarce in the mental health wards.
The young Territorian was instead transferred to the general ward in the middle of the night as a mental health outlier, to be monitored constantly by a security guard.
The inquest into the 24-year-old's death heard the guard had not been briefed on Ngalarina's medical history and they were found dead in the hospital bathroom the next day with an empty bottle of deodorant on the floor.
"One of the main issues ... was the decision to transfer late at night ... and the failure to communicate the risks of VSA to both nursing and security who were tasked to keep Ngalarina safe," counsel assisting Chrissy McConnel said on Wednesday.
A series of failings ultimately resulted in Ngalarina's death, Ms McConnel said.
Luke Butcher from Royal Darwin Hospital told the inquest the death was classified as a "sentinel event", meaning it was "preventable and resulted in serious harm".
Dr Butcher said the hospital had put in place a number of preventative measures since the incident, including a handover form for security staff and better VSA training for nurses.
However, Ms McConnel said the measures were inadequate and evidence of nurses did not reflect any new learnings.
"Neither of those nurses have received any training – whatsoever – in dealing with mental health patients," Ms McConnel said.
Ms McConnel said it was critical general nursing staff were provided with the skills to deal with mental health patients.
"Something has to happen now. Will it take another death for RDH to realise that this is unsatisfactory?" she said.
RDH admitted the best care for mental health patients was in specialist wards, though the inquest heard the capacity does not match the need.
NT Coroner Elisabeth Armitage will hand down her findings at a later date.
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Aboriginal Counselling Services 0410 539 905
