Background Facts

Mrs Mansfield suffered from Bipolar Affective Disorder, which was managed by the use of lithium and Electro Compulsive Therapy (ECT). The prolonged use of lithium caused chronic kidney disease and renal toxicity. She also suffered from depression, type 2 diabetes, hypertension, coronary artery disease and hypercalcaemia.

Approximately three weeks prior to her death, Mrs Mansfield refused to undergo ECT which her treatment team considered essential. An application was made to the Mental Health Tribunal for an order under the Mental Health Act 2013. The Tribunal made a treatment order on 22 July 2015 to remain in force until 22 October 2015. The order provided that Mrs Mansfield was to be detained for treatment at the Royal Hobart Hospital (RHH) as an inpatient to undergo ECT.

On admission to the RHH, Mrs Mansfield was accommodated in the Department of Psychiatric Medicine in a room that was approximately 60 or 70 metres from the nurses’ station. ECT was commenced and her usual medications were continued. Medical records suggest there was no obvious improvement in Mrs Mansfield’s condition, although it equally did not deteriorate. She was immobile at times, exhibiting clear signs of depression and refusing to eat or drink. On other occasions she seemed to have elevated “highs”.

On 1 August 2015, Mrs Mansfield experienced a fall in her room and fractured her femur. She passed away the following day on 2 August 2015.

Mrs Mansfield’s daughter objected to an autopsy being conducted upon her mother. The forensic pathologist could therefore only examine Mrs Mansfield’s body and review her medical records. The forensic pathology expressed the opinion that the cause of Mrs Mansfield’s death was complications arising from the fracture of her left femur, sustained from the fall.

After Mrs Mansfield’s death, her daughter made several complaints about her mother’s treatment, including that:

  • she requested staff at RHH take Mrs Mansfield off anti-psychotic medication but this did not occur;
  • the RHH failed to take adequate steps to prevent against the risk of a fall. Mrs Mansfield had virtually no history of falls and was assessed for a falls risk on admission;
  • another nurse (Nurse J) subsequently completed a second falls risk assessment and considered Mrs Mansfield to have an “extremely high” risk. This assessment was not contained within the medical records, nor was there any progress notes about an alleged conversation between Nurse J and other staff about his assessment. Nurse J alleged that someone must have removed his assessment from the medical records;
  • the room Mrs Mansfield was accommodated in was unsuitable due to its distance from the nursing station and the absence of a call bell and motion detectors; and
  • the care provided by RHH generally, and post fracture, was inadequate.


The Coroner concluded that Mrs Mansfield died as a result of complications arising from the femur fracture following an unwitnessed fall in her room. In relation to the complaints made by Mrs Mansfield’s daughter, the Coroner found:

  • Mrs Mansfield required anti-psychotic medication and it was appropriate that this medication continued to administered;
  • RHH’s falls risk assessment on admission was appropriate and carried out in accordance with the relevant guidelines using accurate information provided by Mrs Mansfield’s daughter;
  • he did not accept Nurse J’s evidence that he completed the second falls risk assessment, that he upgraded Mrs Mansfield’s falls risk to ‘extreme’, that he placed the falls risk assessment in Mrs Mansfield’s medical records, and that the document had been removed by a person unknown;
  • while motion sensors would not have prevented Mrs Mansfield from falling, they should have been available for use in light of Mrs Mansfield’s recorded unwillingness to move at all;
  • overall, Mrs Mansfield’s psychiatric acute care and medical care post-fracture was of a good standard.

The Coroner concluded that the care and treatment of Mrs Mansfield was, subject to some qualifications, of an appropriate standard. Those qualifications are that, the supervision of Mrs Mansfield could have been improved, she could have been located closer to the nurses’ station, motion sensors should have been available and a call button should have been in place.


The Coroner found that in the circumstances of Mrs Mansfield’s death, the only recommendation necessary was that in every case where the death of a patient at the RHH is the subject of an investigation, all records should be preserved and maintained until the conclusion of that investigation. This recommendation arose as Mrs Mansfield’s original physical medical record had been destroyed by the time of the inquest. No recommendations were required as to the RHH facilities, as the Department of Psychiatry had taken appropriate steps since Mrs Mansfield’s death. In particular, the Department was transferred to a new purpose-built unit which is divided into three smaller units based on the level of patient acuity. The Coroner concluded these changes are likely to lead to an improvement in patient care.