The family of a Tiwi Islands woman who died at an acute mental health facility have performed an emotional tribute to their much-loved family member on the final day of a coronial inquest into her death.

WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains the name and image of a person who has died, used with the permission of their family.

Pukumani Alimankinni, as she is known for cultural reasons, died in August 2021, about a day-and-a-half after she was admitted to Royal Darwin Hospital's (RDH) secure mental health ward, the Joan Ridley Unit (JRU).

Her death has been the subject of a five-day coronial inquest at the Darwin Local Court, which has heard testimony from 13 witnesses including family members, medical experts, and nurses who provided care in hospital.

Outside the courtroom on Wednesday, family members and Munupi men and women painted their faces before performing a number of songs, led by senior Munupi man Mr Tungatalum — including the kookaburra song, in honour of Pukumani's totem.

Coroner Elisabeth Armitage thanked Pukumani's family members, some of whom had travelled from the remote Tiwi Islands community of Wurrumiyanga, for their participation in the coronial process.

"I want to thank Pukumani's family for bringing so much warmth, joy, culture, country, and family to Pukumani's inquest," she said.

"I have learned from you that Pukumani was very much-loved by her family and community, that you all loved and grieve her passing."

Coroner hears closing submissions

Inside the courtroom, family members cried as each of the parties delivered their closing submissions.

The lawyer representing NT Health, Tom Hutton, acknowledged the "considerable shock and anguish" that had been caused by Pukumani's death, and said the department took "full responsibility" for the failings that had contributed to her preventable death.

Counsel assisting the coroner, Beth Wild, canvassed several issues and failings the coroner is expected to consider when making her final recommendations.

Among the key issues she highlighted were bed blocking at the RDH mental health ward and the range of medications and anti-psychotics given to Pukumani while she was in the emergency department.

Ms Wild also noted the failure of staff to conduct "the required prescribed observations of Pukumani overnight and, with that, the non-commencement of CPR for seven minutes after she was found unresponsive".

She asked the coroner to consider recommending additional training for staff in the JRU to handle emergency medical situations.

Counsel representing the family, Hannah Donaldson, suggested the coroner consider making a recommendations to NT Health for an alternative model for the prescription of medications in the ED.

"Your Honour might consider a recommendation to NT Health … that a review be undertaken into if or how it might be possible to have a central prescriber who has control of prescribing medication in certain circumstances, namely where there are multiple medications required and a patient has a relevant comorbidity," she said.

Bed blocking in mental health ward a focus

Ms Wild particularly underlined bed block at the JRU as a significant issue.

She told the inquest that had "prevented Pukumani from receiving the appropriate care in a therapeutic environment", and "may have potentially, but almost certainly in my submission, have added to the need for further medication and sedation".

The coroner interrupted her counsel assisting to point out that the issue of bed shortages within mental health units has been an identified issue throughout multiple inquests in the NT in the past.

She said inquests were "being used as an opportunity, again and again, to outline the need and the impact of that need not being met on individuals, on family and staff at the hospital".

Ms Wild urged the coroner to acknowledge and advocate for additional funding for mental health beds, as well as additional staff to monitor those beds, in her recommendations.

That submission was also reinforced by other parties, with Mr Hutton telling the court that work to expand the mental health unit was already underway.

"Further beds are in the process of being constructed … that is not to say more does not need to be done," he said.

NT Health will provide further written submissions in coming weeks.