A troubled Aboriginal woman who died in custody in the Northern Territory did not have access to the mental health experts she desperately needed to see, a coroner has found.
Naomi Smith, 26, likely died from a pulmonary embolus - a blood clot in her lung - on July 7 last year at Royal Darwin Hospital.
She had been flown under sedation from Alice Springs to Darwin less than four days earlier with severe mental health issues.
She had repeatedly tried to kill herself immediately after being released from a mental health unit, including setting herself on fire at a petrol station, leading to her arrest.
The Alice Springs hospital including its mental health team lacked the expertise to deal with Ms Smith's issues, including diagnoses of a borderline personality disorder, post-traumatic stress disorder and depression, NT Coroner Judge Greg Cavanagh said.
A more specialised Forensic Mental Health Team based 1500km away in Darwin should have been involved earlier, he found.
Ms Smith had been removed from her parents aged 12 in Townsville due to long term physical and sexual abuse by her father and brothers.
She was also popular and "very gifted at drawing, painting, sculpting and writing", according to her adopted sister Emily Brooker.
The hospital had pushed her on to the police and corrections who would send her back to the mental health service because nobody could deal with her escalating behaviour, Judge Cavanagh found.
"The repeated rejection of Naomi by each service, particularly the mental health service, is likely to have exacerbated Naomi's distress and deteriorating mental state," he said.
The clots were believed to be related to Ms Smith's obesity and poor general health but could also have been caused by the fact she had been restrained in a chair because of threats of self-harm.
"It should have been clear that there was a need for intervention and assistance from the Forensic Mental Health Team based in Darwin," Judge Cavanagh said.
"There was no forum in which the agencies could jointly organise a management plan."
He has recommended the Top End Health Service ensure the Forensic Mental Health Team provides appropriate service to Central Australia and early intervention for complex cases.
He also recommended a multi-agency forum be established including Health, Ambulance, Police and Corrections to "enable a proactive and clear multi-agency response to complex cases".
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