A Queensland coroner has found mistakes by staff at the Gold Coast University Hospital contributed to the death of Renae Jean Mann in 2014.
She sat alone in the mental health assessment waiting area when her heart stopped due to toxic effects of the drug amitriptyline.
The 47-year-old was unable to be revived.
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Today, Coroner James McDougall delivered his findings to the Southport Coroners Court, saying there were clear mistakes made by hospital staff.
He told the court no nurses saw Ms Mann for about 45 minutes as she sat in the waiting area.
Mr McDougall also said her discharge from the hospital’s emergency department to the mental health assessment area had been premature.
The death prompted a full review of the practices by the Gold Coast University Hospital.
Executive Director of Clinical Governance Dr Jeremy Wellwood offered the hospital’s sincere condolences to Ms Mann’s family.
“One can only imagine what a difficult time it’s been for Ms Mann’s family after this unexpected and tragic death,” he said.
“Significant changes have been put in place to make things safer for the next person.”
“These changes have been considerable, significant and lasting.”
Under the reforms, all Gold Coast University staff must medically sign off a patient from the emergency department to the mental health ward.
There’s been improved training in basic life support and staff has been taught a variety of processes when dealing with mental health patients.