A 2017 opinion piece on chemical restraint

https://insightplus.mja.com.au/2017/8/chemical-restraint-or-lethal-injection

In 2026 there still is no national consensus guideline on sedation for acute behavioural disturbance . There is no formal training course albeit ANZCA have published a 2019 policy on sedation standards for acute behavioural disturbance trying to advocate for minimum safety standards. In 2017 , only Qld & NSW guidelines advocated for ketamine sedation in thirdline use for extreme agitation . In 2026 , Victoria and WA guidelines have now included this . Sadly 3 sedation related deaths of mental health patients have occurred in Northern Territory in last 10 years . All were female Indigenous Australians living in remote communities requiring aeromedical transport . Tragically one was intubated (as form of chemical restraint) for transfer and died of pulmonary embolus few days later after prolonged intubation due to mental health bed unavailability (https://agd.nt.gov.au/media/docs/inquest-finding-pubications/2018/D01162017-Naomi-Smith.pdf)

The second patient was aeromedically transported with ketamine sedation but then after admission was oversedated with IM medication and not adequately monitored (https://localcourt.nt.gov.au/sites/default/files/decisions/2025_ntlc_3_inquest_into_the_death_of_pukumani.pdf)

The third patient similarly was transported to hospital with ketamine sedation then apparently oversedated with benzodiazepines . The coronial inquest is yet to publish its findings ( https://www.abc.net.au/news/2025-10-20/nt-kumanjayi-brogus-inquest-psychiatric-patient-sedation/105912198 , https://www.abc.net.au/news/2026-02-06/kumanjayi-brogus-inquest-nt-alice-springs-hospital-death/106309452)

The NT coroner has questioned whether ketamine sedation was contributing factor in these deaths or at the least a worsening of psychosis after administration for transport. I can say Queensland has never experienced this and we are the state that has the longest experience in ketamine sedation for aeromedical retrieval of acutely agitated patients. In the early years we carefully examined/audited this as we knew it was an obvious concern but receiving psychiatrists I worked with found no worsening of psychosis. I propose that any worsening of agitation/psychosis noted after ketamine sedation for transport is due to other factors such as prolonged stay in ED due to mental health bed unavailability. When ketamine is given with adjunctive sedatives like droperidol or propofol or midazolam , there is often no worseing of agitation after ketamine sedation wears off . Like any procedural sedation if you wake up into a noisy , bright environment like an ED you may become overstimulated and agitated . This can be mitigated though.

Sadly sedation related deaths are still occuring across rural Australia in acutely agitated patients requiring transport to tertiary mental health care. The intubation related death was preventable in my opinion as ketamine sedation has been shown to avoid intubation related complications . Sadly NT is a current hot spot for these deaths & it seems to be harming Indigenous women moreover. we can do better . We must.

Editor , Dr Minh Le Cong