Coroner recommends hospital improve cross-border communication after patient’s death

A coroner has called for a simpler electronic medical-record system at a hospital straddling the New South Wales and Victoria border after a patient waited nearly five hours for a ward transfer before she died.

Deputy State Coroner Rebecca Hosking made the recommendation in findings into the death of 46-year-old Kate Manley at Albury Hospital on November 16, 2022. The inquest examined the care she received at Nolan House, an acute mental health unit, and in the hospital’s medical wards during the five days before her death.

Nolan House operates in New South Wales but must also comply with Victorian law under an agreement between the two state health departments. Albury Wodonga Health executive Danielle McLeish told earlier hearings that the hospital used several linked systems to track patients and meet both states’ requirements. Managing those systems could be confusing for staff.

Hosking found that Manley’s transfer was delayed as her condition deteriorated. She had been diagnosed with catatonia and had eaten or drunk almost nothing at one point for nearly 48 hours. The coroner said the transfer “ought to have been undertaken more quickly” and found that Manley would have benefited from immediate intravenous therapy. However, the findings said there was no evidence a faster transfer would have prevented her death.

Manley stopped breathing shortly after midnight, and staff performed CPR. The cause of death was later identified as a pulmonary embolism, a blood clot in a lung artery. Hosking also found that venous thromboembolism assessments at Nolan House were inappropriate and called for clearer protocols separating psychiatric care from physical medical treatment.

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Given the level of deterioration, her transfer ought to have been undertaken more quickly.