The hour that broke this woman’s heart
AN hour before Renae Jean Mann died in the Gold Coast University Hospital mental health unit after a drug overdose, her mother was told she could visit her later that day.
But then later the mother, Lynette Mansfield-Morley, received a phone call from a social worker telling her doctors had been unable to save her daughter from the overdose.
Coroner James McDougall yesterday handed down his findings into Ms Mann's death on May 14, 2014, ruling the hospital had made mistakes but their steps to ensure it never happened again were "sufficient".
The inquiry had been told that less than 24 hours after Ms Mann was admitted to the emergency department after overdosing on antidepressants on May 13, 2014, she died in a mental health assessment pod after not being checked for 45 minutes.
Ms Mann's mother Lynette Mansfield-Morley yesterday told the Bulletin after the inquest concluded about the shock she felt when the social worker broke the news of her daughter's death.
"We found out she was left for 45 minutes without anyone checking the room," she said.
"I think it was shock and disbelief.
"How could they have told me an hour earlier I could see her and then suddenly she dies?"
The inquest had been told one of the mistakes made by the hospital was the gap of 45 minutes when a nurse did not to check on Ms Mann.
Other mistakes included sending Ms Mann from the emergency department without conducting an ECG.
The antidepressant Ms Mann had taken was known for causing heart problems in potential overdoses.
CCTV showed Ms Mann making involuntary movements and unable to walk properly.
The footage also showed a nurse pull Ms Mann down on the bed by her ankles.
After Ms Mann's death, the hospital conducted a review and immediately implemented changes including in-person monitoring in the mental health pod every 15 minutes, more training in resuscitation in the mental health unit and a medical transfer form that needs to be completed by a doctor when transferring a patient from emergency to the mental health assessment pod.
It was those changes that Mr McDougall said in his finding were "sufficient".
He did not give any further recommendations.
Ms Mansfield-Morley said after the inquest yesterday the family was happy with the findings.
"I don't think she died in vain, I think she has made the pathway now for others to be more valued and more looked after … they just take more care and concern," she said.
She said she hoped her daughter's death ensured other patients were treated better.
"She didn't deserve to be left with no dignity," Ms Mansfield-Morley said.
Ms Mann, 43, was a mother-of-three, including a daughter who was a year shy of graduating from university when her mother died in 2014.
"It has scarred our family. We don't have our funny, witty little girl anymore and it has left a really big hole in our family," Ms Mansfield-Morley said.
"I, as a mother, have grieved.
"My daughter was a very unusual girl, there will never be another Renae. She was funny, witty.
"She was never a well person in her life but she used to say to me, 'mum, I'm good at being sick'.
"She would always be smiling. She was always happy and to see my funny, happy, joyful girl lying lifeless and dead and grey on a slab was heartbreaking and it's a memory I will never forget."
Despite the past four years of waiting for answers, Ms Mansfield-Morley said she held no ill-will.
"While we have no bitterness and resentment to the hospital, we have lost my child and we don't want to see this happen to another family," she said.
"We are so pleased they have made all these other things happen at the hospital so that's a great start."
Following the coronial findings, Gold Coast Health executive director of clinical governance Jeremy Wellwood offered condolences to the family.
"The important thing we would like to reiterate to the family and friends of Renae Mann but also to the Gold Coast community at large is that significant changes have been put in place to make everything safer for the next person," Dr Wellwood said.
"These changes have been considerable, immediate and lasting. We are confident that this will make things safer in the future."
Dr Wellwood said staff were also upset by Ms Mann's death.
"On this particular occasion we haven't got things right and it has been quite harrowing for the staff as well," he said.
Dr Wellwood said changes implemented would remain in place.