Coroner finds Allyson Bailey who died in 'seclusion' wasn't properly 'medically cleared'
Deputy State Coroner Rebecca Hosking ruled Allyson Bailey, 42, died as a result of complications from pneumonia and sedative drug toxicity prescribed by medical professionals.
"It's clear the term 'medically cleared' means different things to different people," Magistrate Hosking said in her findings which were handed down in the State Coroners Court in Lidcombe today.
The coroner also found Ms Bailey's transfer from Tamworth Base Hospital's Intensive Care Unit (ICU) to the nearby Banksia Mental Health Care unit was "inappropriate".
Ms Bailey was found unresponsive and later died in a secluded room of the Banksia unit on July 7, 2020, hours after her involuntary transfer to the facility.
Emma Sullivan, counsel assisting the coroner, told the inquest in July that Ms Bailey presented to Tamworth Base Hospital more than 50 times in the two years leading up to her death.
Ms Bailey struggled with a substance abuse disorder, often became violent, and was unable to be physically controlled.
"[Ms Bailey] was far and away the most difficult mental health patient I have seen in my career," Tamworth Base Hospital senior intensive care specialist Guyon Scott told the coroner.
Dr Scott denied he medically cleared Ms Bailey to be transferred.
Contrary to Dr Scott's given evidence, Dr Andrew Clift told the inquest "I have a crystal clear memory of [the medical clearance]".
Believing her behaviour was not being caused by a medical condition, Ms Bailey was cleared for clinical transfer to the mental health unit.
Tamworth consultant psychiatrist Dr Clive Stanton was not working the day Ms Bailey was admitted, but gave evidence he would not have accepted her at the mental health unit.
Magistrate Hosking found there was a breakdown of communication.
"[Ms Bailey's] transfer was inappropriate, there should have been more consultation," she said.
"She was not correctly diagnosed for pneumonia."
Magistrate Hosking recommended the Hunter New England Local Health District (HNELHD) review its transfer of care policies, as well as guidelines for treating patients with acute behavioural disturbance.
The court heard that patients transferred from the ICU to the mental health unit usually happen "safely".
Psychiatry registrar Dr Sam Hume told the inquest he was given a brief handover when Ms Bailey arrived at the mental health unit but it was clear to him it was a "complex transfer".
"She was running around, very disorganised and running into walls with quite a lot of force," he said.
"I had never seen a patient like this before and not since."
The court heard staff were unable to conduct medical assessments on Ms Bailey when she was transferred to the seclusion room at Banksia about 2:45pm on July 6.
Almost 10 hours later doctors saw Ms Bailey motionless and started CPR, but she was pronounced dead at 12:34pm.
The coroner recommended the HNELHD also review the management of patients in seclusion.
"The seclusion orders were appropriate, but the monitoring was inadequate. There should have been escalation," Magistrate Hosking said.
She did recognise that many of the policies had been updated since Ms Bailey's death and it was clear the medical professionals involved were deeply impacted by the event.
In a written statement to the ABC Ms Baileys daughter, Sarah Potter, said she always recognised how difficult it was for medical professionals to try and help her mother.
Ms Potter said she was happy with Magistrate Hosking's findings, even though they were difficult to hear.
"Despite all the sadness and pain of the situation I am so thankful they didn't let my mum just become a name on a file."
Ms Potter says she treasured the memories of riding horses with her mother as a child.
"She wasn't being heard or listened to when she was alive, but she's being heard now," Ms Bailey's daughter said.
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