Finding into death of Elizabeth Honor Ewart

55y · Female·Unascertained

Elizabeth Ewart, aged 55, died at The Melbourne Clinic on 27 February 2017. She had bipolar disorder, anxiety and schizoaffective disorder. After administering PRN Olanzapine 2.5mg at 4:35pm for agitation, Nurse Cook was approached by Ms Ewart (the sister) expressing serious concern about Lizzie's condition. Ms Ewart claims she told Cook Lizzie was in a 'terrible state' and wanted Dr T. called; Cook denies receiving this information and claims Ms Ewart only reported her as 'sleepy'. The inquest focused on whether Cook should have assessed Lizzie following family concerns. The coroner found the cause of death unascertained, making causation determination impossible. Despite Expert opinions that assessment should have occurred, the coroner could not definitively resolve the contradictory accounts on the balance of probabilities. No adverse findings were made against Cook. The case highlights gaps in psychiatric facility policies for monitoring patient physical wellbeing during routine visual observations, particularly when sedating medications are administered.