A coroner has stopped short of blaming Wollongong Hospital for the suicide death of a man two days after he was admitted to its mental health unit.
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Deputy State Coroner Geraldine Beattie conceded the man's case could have been handled differently in the days before his death on March 12, 2012, but said the hospital and staff were not to blame.
"With the benefit of all the documentary and oral evidence, including expert opinions, one could conclude that different decisions could have been made about [the man's] care and treatment," Ms Beattie said following a two-day inquest held at Albion Park this week.
"However, the evidence and conclusions are not indicative of systemic failure [in the hospital] and I do not find that there are systems issues that can and should be remedied.
The findings have disappointed the man's devastated family, who believe he should have been more closely monitored.
"The family believe that more should have been done to keep their loved one safe," lawyer Anna Walsh told the Mercury. "He was acutely unwell when admitted to the hospital and should have been more closely observed."
The inquest heard the man, a father of three, was stressed from work in the months before his death but had generally been a "stable, functioning adult ... with no history of psychiatric care".
On March 9, three days before his death, he was admitted to hospital after making a serious attempt to take his own life.
He was released into the care of his family the following afternoon, however suffered an apparent episode on his release, running from the hospital, believing he was about to be killed.
He was returned to the hospital and immediately put into the mental health ward on high-level watch. The next day his watch level was reduced from every 10 minutes to every 30 minutes.
The man was found dead in the ensuite the following morning, having placed clothing under the bed covers to make it appear that he was asleep.
The doctor who carried out the autopsy believed he died one to two hours before he was found at 7.50am.
Ms Beattie said the man's tragic death, although not the fault of hospital staff, did highlight the need for greater communication between nurses and doctors on levels of observation.
The court heard that the hospital had since made changes to its patient observation practices.