Inquest into the death of Allyson Bailey

Case Number: 2020/200873

Date of Findings: 13 August 2025

Magistrate: Deputy State Coroner, Rebecca Hosking

CORONIAL LAW - death in hospital (not anticipated); interaction between provision of physical and mental health treatment, impact of Covid-19 on hospital care.

Responses

Recommendations

To the Chief Executive of the Hunter New England Local Health District (HNELHD)

1. That there be a review of transfer of care/discharge processes and procedures in Tamworth Hospital for patients with complex mental health issues who are in high acuity areas (such as the Emergency Department (ED) or Intensive Care Unit (ICU)), whose care is then transferred to the Banksia MHU. The review should consider the issues raised in the evidence of Dr Clive Stanton and Dr James Zurek and involve relevant stakeholders / clinicians from high acuity areas within Tamworth Hospital (such as the ED and ICU) and from Banksia MHU.
2. That there be a review of HNELHD documentation, policy and procedure relating to the management of acute behavioural disturbance in mental health units (including as to the use of restraint and seclusion of patients), including as to the following matters: 

a)to ensure that the ‘Seclusion Authorisation’ form includes: 

i.provision for ‘time stamps’ on relevant forms (for example, the ‘Seclusion Authorisation’ document) 

ii.the number of seclusion orders made (i.e. whether the order is the first, second etc) 

iii.reference to the relevant procedures or policies in appropriately prominent terms. 

b)to ensure that, so far as practicable, the relevant policy provisions relating to seclusion, restraint (including rapid tranquilisation), vital sign observations and escalation (including where vital sign monitoring cannot be undertaken and/or there is no response to intramuscular parenteral treatment) are set out in a clear manner (for example, by reference to a flow chart or a single document).

3. That there be consideration of how the lessons learned from Allyson Bailey’s death could be used within HNELHD as a case study for learning by other clinicians including in relation to transfer of care (and issues with the terminology of ‘medically cleared’ and ‘medical clearance’ as being potentially misleading regarding a patient’s physical health), monitoring and escalation issues (including potentially in a ‘reflective workshop’ forum).

4. That consideration be given to a review of the Clinical Guideline ‘Mental Health: Management of Acute Behavioural Disturbance in HNE Mental Health Units (CG 22_06)’ concerning the Intramuscular (Parenteral) Treatment Rapid Tranquilisation protocol (p 52) by an appropriate person (or body/authority) to ensure: 

a) that it accords with current best practice (on the basis of the current literature); and 

b) that it reflects current prescribing practices within Banksia MHU.