The life of 46-year-old Kate Manley, a cherished family member known for her vivacious spirit, was honored during a recent coronial inquest in Albury. The proceedings examined the circumstances surrounding her transfer from Nolan House, a psychiatric unit at Albury Hospital, to the hospital’s medical ward prior to her passing, which was attributed to a pulmonary embolism.
Coroner Rebecca Hosking is expected to release her findings and recommendations in the coming weeks.
Kate Manley’s family described her as a vibrant, independent mother whose energy and sense of humor enriched the lives of those around her. She passed away at Albury Wodonga Health’s Albury hospital on November 16, 2022, following a suspected pulmonary embolism, a serious condition often linked to deep vein thrombosis.
The five-day inquest into her death recently concluded at the Albury Local Court. During the hearings, Patrick Rooney, the counsel assisting the coroner, read a heartfelt statement from her twin brother, Alex. The statement highlighted Kate’s compassion, creativity, and her ability to bring joy and warmth to her loved ones, illustrating her role as the family’s emotional cornerstone, particularly for her daughter Ruby, who was described as “the center of her world.”
The inquest featured testimonies from various staff members, executives, and medical professionals associated with Albury Wodonga Health (AWH). Following her admission to the hospital on November 11, Kate was diagnosed with catatonia after exhibiting minimal responses during medical evaluations. Tragically, she passed away in the hospital’s medical ward just five days later, after being transferred from Nolan House.
Evidence revealed that there was a significant delay of five hours before Ms. Manley was moved to the medical ward, where her risk of blood clots could have been thoroughly assessed. Mr. Rooney remarked on the unfortunate nature of the delay, suggesting that timely examination and treatment could have made a crucial difference in her care. He emphasized that there were communication breakdowns between the staff of Nolan House and the medical ward regarding the seriousness of her declining condition.
The inquest also looked into how the geographical placement of Nolan House might have contributed to the circumstances surrounding Ms. Manley’s death. Although the unit operates in Albury, NSW, it is governed by Victorian regulations. During the hearings, Dannielle McLeish, the acting director of mental health and wellbeing, explained that the hospital utilized a combination of tracking systems for patient movements. However, the reliance on both paper-based systems required by Victorian laws and electronic tracking created confusion among staff.
Mr. Andrew Way, the former interim CEO of AWH, had previously noted that communication between Nolan House and the medical ward was lacking. During his brief time in the role, he made attempts to engage with frontline staff at Nolan House to address these concerns. He acknowledged that while the systems in place were not flawless, they aligned with expectations for a facility of that size.
In his submissions, Mr. Rooney referenced an earlier coronial investigation regarding the death of Roger Schnelle at Nolan House, which recommended the establishment of a unified electronic medical record for Albury Wodonga Health’s medical and mental health services. He stated that AWH supported this recommendation and encouraged the implementation of a compatible system for both NSW and Victoria.
Lorna McFee, the counsel representing AWH, indicated that the health service had already initiated improvements related to patient transfers and other operational systems since Ms. Manley’s tragic passing. She also conveyed condolences from AWH’s board members to the Manley family.
Coroner Hosking indicated that she plans to issue her findings and recommendations within a month.
