Coroner urges NSW and Victoria to streamline hospital transfers after Kate Manley's death

Deputy State Coroner Rebecca Hosking’s findings on the November 16, 2022 death of 46-year-old Kate Manley highlighted a prolonged wait of almost five hours to move her from the mental health unit Nolan House to a medical ward at Albury Hospital, where she later suffered a fatal pulmonary embolism. The coroner noted that while immediate IV therapy could have helped, there was no evidence the delay caused the death. She identified gaps in VTE risk assessment and prophylaxis, citing that hospital policy requires assessment within 24 hours, which was not followed.

Hosking urged the health departments of New South Wales and Victoria to adopt a unified electronic records system and to develop a specific treatment pathway for catatonia patients, recommending audits of VTE assessments. Albury Wodonga Health has since updated its VTE policies and introduced a new communications tool for staff coordination. The case was remembered by family and friends as a loss of a compassionate, creative individual.