Coroner recommends hospital fix cross-border communication after death

A coroner is urging the New South Wales and Victorian Health departments to improve cross-border communication and coordination at Albury Wodonga Health following the death of a 46-year-old woman. Kate Manley, 46, died on November 16, 2022, after waiting nearly five hours to be transferred from a mental health unit to a medical ward.

Deputy State Coroner Rebecca Hosking made the recommendation as part of her investigation into whether Kate received adequate care during her admission between November 11 and 16, 2022. The inquest found that Kate should have been given immediate intravenous therapy, but there was no evidence that a quicker transfer could have prevented her death.

Kate, who had a history of schizophrenia, depression and other medical issues, was diagnosed with catatonia and admitted to Nolan House, a mental health unit based in NSW but subject to both state laws. On the night of her death, she waited nearly five hours to be transferred to a medical ward. Hosking recommended implementing better communication and a streamlined electronic record system to assist in hospital ward transfers, as well as clearer protocols for distinguishing psychiatric from physical treatment.