Mann, Renae Jean

Contributing factors

• premature medical discharge from acute ED without completion of ordered troponin testing
• failure to obtain further ECG prior to medical clearance despite abnormal baseline findings with T-wave changes
• inadequate assessment immediately prior to transfer to mental health assessment pod
• misattribution of unsteady gait and involuntary movements to behavioural issues rather than medical deterioration
• insufficient observation and monitoring in mental health assessment pod—45-minute gap with no staff entry despite patient displaying no movement after 6:49 AM
• reliance on CCTV footage alone without adequate physical observations by nursing staff
• high ED volume and understaffing limiting quality of medical oversight
• lack of formal documented medical clearance criteria and process

Coroner's recommendations

1. Maintain implementation of formal ED Triage/Referral to Acute Care Team Form mandating documented medical clearance by senior practitioner before transfer to mental health assessment area
2. Continue mandatory constant visual observations in mental health assessment pods with documented 15-minute observation intervals including respiratory rate
3. Ensure all staff allocated to mental health assessment pods are proficient in Basic Life Support measures
4. Establish strict admission criteria for mental health assessment pods excluding patients with medical conditions that may result in clinical deterioration
5. Implement documented criteria-based medical clearance prior to discharge from acute ED, to be pre-specified by appropriately qualified senior doctor
6. Conduct serial ECG and troponin testing in all patients with suspected tricyclic overdose, particularly when baseline ECG abnormalities are identified
7. Couple CCTV monitoring with adequate physical observations rather than relying on CCTV footage alone
8. Ensure bedside handover documentation using SBAR methodology for all patient transfers to or from mental health assessment pods
9. Provide ongoing education to ED and mental health staff regarding clinical deterioration detection, particularly avoiding unconscious bias toward mental health patients
10. Implement structured handover communication protocols ensuring all relevant clinical information is conveyed to receiving teams