Albury Wodonga Health operates under a memorandum of understanding that requires it to follow health laws in both New South Wales and Victoria, and the organisation uses several combined tracking systems to meet those obligations.

During the inquest, Deputy State Coroner Rebecca Hosking found that venous thromboembolism (VTE) risk assessments were not carried out correctly and that staff were often confused by the multiple tracking systems in use.

She also noted that many clinicians were unclear about the policies, partly because some staff missed orientation or were temporary locum workers.

To address these problems, Hosking recommended that the health departments of NSW and Victoria work together to create a streamlined electronic record system that would improve coordination of patient transfers across the border.

The case shows how disjointed record‑keeping and unclear procedures can jeopardise patient safety, highlighting the need for a single, electronic platform at Albury Wodonga Health.