A Queensland coroner has expressed his disbelief that a woman was left unattended at a Gold Coast hospital for almost an hour as she died from a prescription drug overdose.
Renae Jean Mann, 47, was left alone in a mental health assessment waiting area at the Gold Coast University Hospital on May 14, 2014.
During that period her heart stopped due to the acute toxic effects of the drug amitriptyline.
Delivering his findings at Southport Court on Wednesday following an inquest into Ms Mann's death, coroner James McDougall said it was clear mistakes and omissions by hospital staff had contributed to her death.
"Neither the AIN (assistant in nursing), or the RN (registered nurse), entered the room for some 45 minutes," Mr McDougall said.
"This failing is hard to fathom and clearly demonstrates a lack of sufficient observation as well as the obvious limitations of relying on CCTV footage to effectively monitor patients."
Mr McDougall also found Ms Mann's discharge from the hospital's emergency department to the mental health assessment area had been premature.
Given her medical history and her prescriptions for amitriptyline and diazepam, she should have been held longer for medical observation, he said.
Mr McDougall welcomed changes to procedure implemented by the hospital following Ms Mann's death, recommending they be continued to prevent any future tragedies.
Ms Mann's mother Lynette Mansfield said her family had been scarred by the loss of her daughter.
Ms Mansfield said she welcomed the coroner's findings and while she doesn't hold any bitterness to the hospital, it was clear the death was avoidable.
"We don't have my daughter anymore and she passed away because of medical staff making mistakes," Ms Mansfield said outside court.
"It's as simple as that and it shouldn't have occurred."
Gold Coast Health offered their condolences to Ms Mann's family and sought to reassure the public the changes welcomed by the coroner had increased patient safety.
"These changes have been considerable, immediate and lasting. We're confident that this will make things safer in the future," clinical governance executive director Jeremy Wellwood told reporters.
Ms Mansfield said she was hopeful the legacy of her daughter's death would be the new hospital procedures saved lives.
"I don't think she died in vain," she said.
"She has made the pathway now for others to be more valued, more looked after and treated like a person."
Australian Associated Press