The Circumstances Surrounding a Woman’s Death in Darwin’s Largest Hospital

In the heart of Darwin, a heartbreaking case has emerged, shedding light on critical flaws within the healthcare system. The Northern Territory coroner’s findings reveal a troubling combination of understaffing, a dire shortage of mental health beds, and communication breakdowns among hospital staff, all of which contributed to the untimely death of Pukumani Alimankinni, a Tiwi woman.

In August 2021, Pukumani was involuntarily admitted to the Royal Darwin Hospital (RDH) following a severe psychotic episode in her home community of Wurrumiyanga, Bathurst Island. Her journey through the hospital’s chaotic emergency department, where she spent 62 hours, was marked by distress, agitation, and hallucinations. Despite her clear need for immediate care, the system failed her.

Transferred to the Joan Ridley Unit (JRU), RDH’s secure mental health ward, Pukumani was monitored only via CCTV, with no physical checks conducted by the nursing staff. Tragically, just a day and a half after her arrival at the JRU, she was found unresponsive on the morning of August 8. The inquest revealed that her death was attributed to acute respiratory failure, compounded by chronic obstructive pulmonary disease, obesity, and the effects of multiple antipsychotic and sedative medications.

This devastating case prompted a mandatory coronial inquest, which unfolded over five days last year, culminating in a comprehensive 50-page report released by the coroner. Pukumani Alimankinni’s story serves as a poignant reminder of the urgent need for systemic change in mental health care to prevent such tragedies from occurring in the future.