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Bowling, Dianne Judith

Deceased

Dianne Judith Bowling

Demographics

59y, female

Date of death

2011-10-29

Finding date

2014-07-18

Cause of death

Mixed drug toxicity, with metoprolol at toxic level; coronary atherosclerosis as contributing factor

AI-generated summary

Dianne Bowling, a 59-year-old woman with a 40-year history of bipolar disorder, died from mixed drug toxicity involving a toxic level of metoprolol. She had a history of three previous overdoses and was under community mental health services. In October 2011, community workers noted signs of deterioration (anxiety, insomnia, emotional blunting) consistent with relapse. The interim case manager (RN Gulliver) provided appropriate clinical care, including urgent home visits and earlier psychiatric appointments. However, communication with non-government organisation staff was perceived as dismissive, though he ultimately acted appropriately on their concerns. The coroner found the psychiatric assessment by the registrar was reasonable given available information. While the Crisis Management Plan was well-intentioned, confusion about which version was current created administrative issues. The coroner found no adverse findings regarding clinical assessment or care, though recommendations were made to simplify documentation and improve communication protocols with community agencies.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatrygeneral practice

Error types

communicationsystem

Drugs involved

metoprolololanzapinequetiapinesodium valproatetemazepamoxazepamthyroxine

Clinical conditions

bipolar 1 disordergeneralised anxiety disordermelancholic depressioncognitive deficits from previous strokehypertensionemphysemacoronary atherosclerosis

Contributing factors

  • Long-standing bipolar 1 disorder with recurrent episodes
  • Mental health relapse and deterioration in October 2011
  • Signs of relapse not acted upon with sufficient urgency
  • Cognitive deficits from previous stroke limiting her ability to articulate concerns
  • Increasing frequency and severity of depressive episodes
  • Existing suicide attempts history (1992, 1999, 2009)
  • Coronary atherosclerosis and emphysema

Coroner's recommendations

  1. Simplify and modify Crisis Management Plans to be more user-friendly for community support agencies and non-government organisations
  2. Ensure only one current version of Crisis Management Plans is accessible and clearly marked as the active plan to avoid confusion among clinical staff
  3. Develop and implement audit systems to ensure compliance with new Acute Management Plan policies, ensuring plans are saved in CIMHA and EDIS for accessibility across services
  4. Review and improve communication protocols and handover procedures when case managers take leave, particularly attending case review meetings prior to takeover
  5. Enhance communication and collaboration between mental health services and community-based non-government organisations to ensure their observations about patient deterioration are appropriately validated and acted upon
  6. Continue review of policies 'Navigating the Metro North Mental Health Service-TPCH' and 'Communicating with the Mental Health Service-TPCH' through interagency meetings to improve clarity and utility
  7. Develop better guidance for community support workers about escalation and emergency assessment that does not place clinical decision-making responsibility on non-clinical staff
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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