Patients regularly go missing from Wollongong Hospital, an inquest into the death of Ariel Vega heard yesterday.
The 78-year-old Mount St Thomas man went missing from the hospital's Ward Three East about 6.30pm on August 8, 2011, after having minor surgery earlier that day.
He was found dead 17 hours later, having broken his neck after falling face down through an aluminium-framed window within a plant room in a restricted part of the hospital.
His grieving family returned to court this week for the second half of an inquest into his death.
Members of the security team involved in the search for Mr Vega in the crucial hours after he went missing gave evidence that an average of two patients went missing from the hospital each week.
Security officer Travis Boyd said most had "gone out for a smoke" or "down the street" and were back within half an hour.
"They go missing fairly frequently ... a couple of times a week," he said. "We'd never had anyone missing in the hospital itself."
Mr Boyd said he had reviewed CCTV footage of the hospital exit doors when notified that Mr Vega was missing. He had not checked the plant room or adjoining atrium as the doors to these "should have been locked".
It was only the next morning that a review of CCTV footage overlooking that area had shown Mr Vega reaching out to open the atrium door.
Counsel assisting the coroner Peter Aitken said that despite the regularity of missing patients, there had been no written protocol for search efforts in place at the time of the incident, although that had since been rectified.
Mr Aitken suggested the security response after Mr Vega went missing was "haphazard".
"Information wasn't being logged, so it would have been hard to work out not only where had been searched, but when it had been searched," he said.
The inquest also heard that a fire alarm in the renal unit of the hospital on the afternoon of August 8, 2011, triggered a series of security doors to unlock, including the door to the atrium which Mr Vega is believed to have gone through to get to the plant room.
Security officer Denis Missiato told the court that after a fire alarm, which occurred regularly, security officers would routinely relock the doors remotely from a central computer system.
"The doors open electronically when there is a fire trip, then we relock them on the computer electronically," he said.
Hospital manager at the time of the incident Malcolm Goddard confirmed that the door log for August 8 showed that at 4.32pm the fire alarm had tripped the doors - it was not until 6.05pm that the doors had been relocked electronically.
However he conceded that even if the electronic system showed that the door was closed, it was possible that it was not locked.
Mr Goddard rejected suggestions that the atrium area was used by staff sometimes as a smoking area. He also said he had never seen the door propped open by any type of wedge.
Mr Goddard also confirmed that an average of two patients went missing each week. He said a high percentage of these had "gone out for a meal and a drink".
The inquest continues today.