Inquest into the death of Kate Manley
Deceased
Kate Manley
Demographics
46y, female
Date of death
2022-11-16
Finding date
2026-08-31
Cause of death
Pulmonary embolism (saddle embolus in pulmonary trunk)
AI-generated summary
Kate Manley, 46, died from a pulmonary embolism while an inpatient at Albury Base Hospital receiving psychiatric care for catatonia. She was not prescribed prophylactic anticoagulation despite risk factors including immobility, dehydration, elevated BMI, and smoking history. The coroner found that prophylactic Clexane should have been prescribed from admission and may have prevented her death. A key failure was the siloed approach to psychiatric and physical healthcare: the psychiatric team was reluctant to prescribe anticoagulants, believing this was the medical team's role, but experts disagreed. Anticoagulation could and should have been prescribed in the psychiatric ward. Additionally, no formal DVT assessment was performed on admission and her transfer to the medical ward was delayed. The case highlights risks of separating mental and physical health care without integrated holistic assessment. Recommendations include implementing electronic medical records compatible with NSW and Victoria systems, establishing a catatonia treatment pathway, educational use of this case, and VTE protocol audits.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to prescribe chemical prophylaxis for venous thromboembolism
- Immobility and reduced mobility
- Dehydration and poor oral intake
- Catatonia
- Elevated body mass index
- Smoking history
- No formal DVT assessment on admission
- Delayed transfer from psychiatric to medical ward
- Siloed psychiatric and medical healthcare systems
Coroner's recommendations
- Advocate with NSW Health and Department of Health Victoria for implementation of an electronic medical record across Albury Wodonga Health services, compatible with systems in both NSW and Victoria, including standardised documents for assessment, formulation and management of risk and patient observations
- Advocate with NSW Health and Department of Health Victoria for implementation of a treatment pathway for patients diagnosed with catatonia
- Use the de-identified facts and circumstances of Kate Manley's death as a case study for educational purposes and training
- Carry out additional audits of the Venous Thromboembolism Risk Management Procedure AWH0221276 and take all steps necessary to ensure appropriate levels of compliance
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