Inquest into mother's death examines Albury Hospital transfer delays

A coronial inquest in Albury examined the death of Kate Manley, a 46-year-old woman who died on November 16, 2022, after being transferred between Albury Hospital's Nolan House and medical ward. Manley, a qualified chef and much-loved family member, suffered a pulmonary embolism, a blood clot emergency related to deep vein thrombosis. The inquest, which concluded after five days, heard testimony from Albury Wodonga Health staff, executives, and medical experts.

Kate Manley was diagnosed with catatonia shortly after arriving at the hospital on November 11, and she died five days later at the medical ward after a five-hour transfer from Nolan House, the mental acute psychiatric ward. Counsel assisting the coroner, Patrick Rooney, noted communication issues between Nolan House and medical ward staff about the severity of Manley's deteriorating condition.

The inquest also explored how Nolan House's location, which operates under Victorian laws, may have contributed to the events leading up to her death.

The hospital has combined systems for tracking patient movements, including paper-based and electronic systems, which have proven challenging for staff to manage. Former AWH interim CEO Andrew Way stated that communication between Nolan House and the medical ward had been ineffective during his brief tenure. Professor Andrew Way testified that he had attempted to address these issues during his time as interim CEO, but they remained consistent with what he expected from a unit of this scale and size.

Coroner Rebecca Hosking is expected to deliver her findings and recommendations within a month. AWH has already taken steps to improve patient transfers and other systems since Manley's death, and a previous coronial inquest into the death of Roger Schnelle at Nolan House had called for a single electronic medical record across Albury Wodonga Health medical and mental health services.