Western Arrernte woman Kumanjayi Brogus Ungwanaka was 34 when she died on 21 November 2023.
The mum of three lived with her family in Hermannsberg-Ntaria, a small community 130 kilometres west of Alice Springs.
Ms Brogus Ungwanaka had been diagnosed with schizophrenia in 2014, and was in the grips of a psychotic episode in the days leading up to the night she died.
In an opening statement at the coronial inquest into her death, counsel assisting the Coroner Sandra Wendlandt told the court medical evidence suggests its cause was "asphyxia death in the context of profound sedation".
"In other words, she was given so many drugs for sleeping that it caused her to stop breathing," Ms Wendlandt said.
Court hears of 'fractured' handover process
Counsel assisting Sandra Wendlandt said that just two days before Ms Brogus Ungwanaka's death, the 34-year-old had received her regular depot injection, a long-term anti-psychotic medication.
The following evening she was brought in to the local clinic by family as she was “not feeling well mentally.”
"Her family were worried, they said she was talking funny, crying uncontrollably and talking to herself," Ms Wendlandt told the court.
She then returned to the clinic the following day and was administered 10mg of diazepam (a tranquilliser) and 10mg of olanzapine orally.
On 21 November, despite Kumanjayi Brogus Ungwanaka being willing to go to Alice Springs Hospital, she was transferred as an "involuntary patient" due to "acute psychosis" as she was "unable to be managed in the community".
Before leaving the clinic she was given midazolam (a sedative) and droperidol (an antipsychotic sedative) intravenously.
Upon assessing Ms Brogus Ungwanaka, the doctor present in the ambulance warned against continuing the same medication following elevated ECG results.
Instead, it was decided to administer a ketamine infusion as "the best way to get to hospital safely".
When she arrived at the hospital there was no bed available and notes suggest they were unaware of her upcoming arrival.
She was given another dose of midazolam (a sedative) once the ketamine appeared to be wearing off.
CCTV shows Ms Brogus Ungwanaka was placed in a wheelchair, unrestrained, and there were no signs of aggression or violence.
Ms Wendlandt told the court the medical chart did not travel with Ms Brogus Ungwanaka, that her medication history was not uploaded to the electronic system, and that the "handover was clearly fractured".
"There is conflicting information as to what informed the decision making and why," Ms Wendlandt said.
"Opinions about the need to sedate were also varied."
Ms Brogus Ungwanaka was finally admitted to the psychiatric ward towards midnight where shortly afterwards it was discovered she was not breathing and was unable to be revived.
The inquest will run for several more days, and will hear further evidence from medical staff and members of Ms Brogus Ungwanaka's family.
