Mann, Renae Jean

43y · Female·acute toxic effects of amitriptyline

A 43-year-old woman with depression was admitted to Gold Coast University Hospital with suspected amitriptyline overdose. After 11 hours of ED monitoring, she was medically cleared and transferred to a mental health assessment pod, despite abnormal ECG findings with T-wave changes not fully investigated (troponin test ordered but not sent). She was unsteady on transfer and displayed involuntary movements attributed to behaviour rather than medical deterioration. Staff failed to observe her in the pod—she made no movements after 6.49 AM but was not checked until 7.33 AM when she was found unresponsive. Autopsy confirmed amitriptyline toxicity with cardiac scarring. Key failings: premature discharge without complete cardiac investigation, inadequate assessment before transfer, and critically insufficient monitoring in the mental health pod. The hospital has since implemented formal medical clearance forms, mandatory CCTV monitoring with 15-minute observations, and staff training.