00:02It was only hours after she arrived at hospital seeking help that Kumanjai Brogas Angwinaka died in November 2023,
00:09with the coroner today echoing NT Health's own conclusion that the mother of three's death was preventable.
00:15Kumanjai Brogas died from cardiac arrest in the context, the coroner said,
00:19of over-sedation and inadequate monitoring, all part of what she described as a string of cascading failures by NT
00:26Health staff.
00:27The coroner wrote that these were failings of individuals working in a system which permitted mistakes to occur,
00:33a system which then did not identify the mistakes or rectify them in time to save Kumanjai's life.
00:39Kumanjai Brogas was given too many drugs and too little care, and this fatal combination caused her death.
00:45The coroner's key recommendation related to NT Health's rapid tranquilisation procedure,
00:50which she said was used but not justified in this case and should only ever be a last resort.
00:55In her findings, the coroner expressed concern that NT Health had overused the procedure
01:00and noted in a previous inquest, it was recommended that the procedure be reviewed
01:04less than two years before Kumanjai Brogas' unfortunate death.
Comments