Coroner probes five-hour transfer lag before Kate Manley's fatal embolism
A coronial inquest in Albury examined why Kate Manley waited five hours to move from a psychiatric unit to a medical ward before dying of a pulmonary embolism.
During a five-day coronial inquiry at Albury Local Court, relatives described Kate Manley as a vibrant mother and chef who died on November 16, 2022, from a suspected pulmonary embolism. Testimony revealed she was first admitted to Nolan House, a mental health ward, and then waited five hours for transfer to the medical ward where clot risk could be assessed. Counsel highlighted communication failures and a confusing dual tracking system that combined paper records required by Victorian law with electronic tools.
Hospital executives, including former interim CEO Andrew Way, acknowledged the shortcomings and noted steps taken to improve patient movement after the case. The acting director of mental health, Dannielle McLeish, called for a unified patient-location source, and the coroner, Rebecca Hosking, will deliver findings and recommendations within a month.
Why it matters
The case underscores how hospital coordination failures can worsen health outcomes and prompts reforms in patient tracking systems.
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