Inquest into the death of Allyson Bailey
Deceased
Allyson Bailey
Demographics
42y, female
Date of death
2020-07-07
Finding date
2025-08-13
Cause of death
pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Baclofen and Pregabalin)
AI-generated summary
Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabalin toxicity) whilst in seclusion in a mental health unit. Critical clinical failures included: inappropriate transfer from ICU to a mental health ward without adequate consultant-to-consultant discussion; inadequate physical observations and vital sign monitoring in the mental health unit due to agitation; failure to escalate care despite non-response to sedation and inability to obtain vital signs; and unclear use of the term 'medically cleared' which created false assurance about her physical health. The underlying pneumonia was undiagnosed and may not have been apparent from initial presentation. Key lessons include: complex cases require specialist input and clear escalation pathways; consultant-level discussions should precede ICU discharge; vital sign monitoring failure should trigger escalation; and terminology like 'medically cleared' can be misleading in complex cases.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- inappropriate transfer from ICU to mental health unit without adequate stabilisation
- inadequate consultant-to-consultant discussion prior to transfer
- failure to perform vital sign monitoring due to patient agitation
- failure to escalate care despite non-response to sedation
- undiagnosed underlying pneumonia
- mixed drug toxicity from baclofen and pregabalin
- misleading use of term 'medically cleared'
- diagnostic overshadowing by acute behavioural disturbance
- ambiguity in escalation pathways when observations cannot be performed
Coroner's recommendations
- Review transfer of care/discharge processes for patients with complex mental health issues transferring from high acuity areas (ED/ICU) to Banksia MHU, considering evidence from Dr S. and Dr Z., involving relevant stakeholders from ED, ICU and Banksia MHU
- Review HNELHD documentation, policy and procedure relating to management of acute behavioural disturbance in mental health units including use of restraint and seclusion to ensure Seclusion Authorisation form includes: time stamps; number of seclusion orders made (first, second, etc); and reference to relevant procedures/policies
- Ensure policy provisions relating to seclusion, restraint, rapid tranquilisation, vital sign observations and escalation (including where vital sign monitoring cannot be undertaken and/or there is no response to intramuscular parenteral treatment) are set out clearly in a single document or flow chart
- Consider using Ally's death as a case study for learning by other clinicians within HNELHD, including transfer of care issues, misleading terminology of 'medically cleared' and 'medical clearance', monitoring and escalation issues, potentially through reflective workshops
- Review Clinical Guideline 'Mental Health: Management of Acute Behavioural Disturbance in HNE Mental Health Units (CG 22_06)' concerning Intramuscular Rapid Tranquilisation protocol to ensure it accords with current best practice literature and reflects current prescribing practices within Banksia MHU
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