The family of a man found dead hours after he discharged himself from Wollongong Hospital - his body outside, surrounded by empty packets of prescription medication - believed he was safe in a Nowra treatment facility when police alerted them to their loss.
The case is the subject of an inquest at Wollongong Coroner's Court this week.
It has brought under scrutiny Illawarra Shoalhaven Local Health District's practice of discharging mental health patients with a week's supply of prescription medication.
Mark Richard Gleeson's body was discovered near a fence on the corner of Railway Parade and Governor's Lane on December 22, 2011. He was 39.
Relatives had dropped him at the Nowra residential drug and alcohol treatment facility Oolong House on December 19, but were not notified when he left to become a voluntary patient at Wollongong Hospital the following day.
Relatives were again not informed when Mr Gleeson discharged himself from Wollongong on December 21, said counsel assisting the coroner, Donna Ward.
"The first they learnt he had left [Oolong House] was when contacted by the police and told of his death ... three days before Christmas."
Toxicology reports showed a cocktail of prescription medicines including anti-psychotic and anti-anxiety agents in Mr Gleeson's system, and indicated his death was "ultimately ... at Mr Gleeson's hand".
He still wore his hospital identification band, prompting police to begin their investigations at Wollongong Hospital.
Dr Anju Abujam, then a psychiatric registrar at Wollongong, told the court Mr Gleeson came to her with a history of depression, anxiety, poly-substance abuse and gambling addiction, and complained of "being influenced and controlled". She said he asked to be discharged after he was refused an increase in medication.
She followed him into his room to encourage his return to Oolong House, and offered to call his parents.
"He said that he had been trouble for his family, so he would not like to trouble them any more, and he's very aware of emergency accommodation around Wollongong."
He had earlier "politely" refused to nominate his primary carer.
Dr Abujam said it was standard procedure to discharge patients with a seven-day supply of their medication, and that patients safely managed these doses "all the time".
She told Coroner Geraldine Beattie the practice was important, as patients had relapsed in the past when their medication was interrupted.
"We have a duty of care to provide him with sufficient quantity of medication for continuity of care," she said.
Dr Abujam said Mr Gleeson had described "off and on" thoughts of suicide, but had been assessed as low-risk.
She suggested alcohol may have played a role in his decision to take all his medication after he left the hospital.