A coronial inquest in Albury has laid bare the critical communication breakdowns and systemic delays that preceded the tragic death of a local mother at Albury Wodonga Health’s Albury campus.

The five-day inquiry, which concluded at Albury Local Court, investigated the circumstances surrounding the death of 46-year-old Kate Manley on November 16, 2022. Ms. Manley, a vibrant mother and qualified chef, died from a suspected pulmonary embolism—a life-threatening blood clot—just days after being admitted to the hospital.

A Family Left Devastated

Throughout the hearings, the court heard moving tributes to Ms. Manley, who was described as the energetic "glue" of her family. In a statement read to the court, her twin brother, Alex, remembered her as compassionate, creative, and independent, noting that her young daughter, Ruby, was "the centre of her world."

Five-Hour Delay and Inter-Ward Communication Failures

Ms. Manley had presented to the hospital on November 11 and was diagnosed with catatonia before being admitted to Nolan House, the hospital’s acute psychiatric ward. However, as her physical health deteriorated, she faced a critical five-hour wait to be transferred from Nolan House to the main medical ward for a blood-clot risk assessment.

Counsel assisting the coroner, Patrick Rooney, told Coroner Rebecca Hosking that "tragically, further examination and treatment would have occurred at the medical ward if there had been more time." He highlighted severe communication gaps between staff at Nolan House and the medical ward regarding the rapid decline in Ms. Manley's physical condition.

The Cross-Border Administrative Nightmare

The inquest also cast a spotlight on the complex administrative hurdles facing Albury Wodonga Health. While the physical facility of Nolan House is located in Albury, New South Wales, it operates under Victorian mental health laws.

This cross-border jurisdiction forced staff to juggle a confusing mix of Victorian-mandated paper-based tracking systems alongside modern electronic records. Dannielle McLeish, the hospital’s acting director of mental health and wellbeing, testified that managing these dual systems was challenging and confusing for frontline workers, emphasizing that "it's important to have a single source for the location of a patient."

Former interim CEO Andrew Way also acknowledged that communication between the two wards had been "ineffective" during the period leading up to the tragedy, though he noted that staff were working under difficult, system-wide constraints.

Urgent Calls for Unified Medical Records

This is not the first time Albury Wodonga Health’s administrative divisions have faced intense scrutiny. The court was reminded of a previous coronial inquest into the death of Roger Schnelle at Nolan House, which resulted in a recommendation for New South Wales and Victoria to implement a single, unified electronic medical record across all services.

Lorna McFee, legal counsel for Albury Wodonga Health, stated that the health service has already implemented proactive measures to streamline patient transfers and minimize communication errors since Ms. Manley’s passing. The hospital board also formally expressed their deepest condolences to the grieving family.

Coroner Rebecca Hosking is expected to deliver her final findings and recommendations within the next month.