A man whose body was found surrounded by empty prescription medication packets within hours of his discharge from Wollongong Hospital died from an accidental overdose, an inquest has found.
Mark Richard Gleeson became intent on leaving the hospital on December 21, 2011, after doctors refused his request for a dramatic increase in medication.
His family believed he was in Nowra drug and alcohol treatment facility Oolong House - where they left him three days earlier - when they learnt he had been found dead in the Wollongong rail corridor.
In Wollongong Coroner's Court on Wednesday, Coroner Geraldine Beattie attributed Mr Gleeson's death to respiratory failure, resulting from the interaction of prescribed medication and alcohol consumed after he left Wollongong Hospital.
The coroner found clinicians at Wollongong had acted properly in letting the 39-year-old father leave with a seven-day supply of medication.
She accepted this was standard practice aimed at ensuring continuity of care for patients who might struggle to get - or finance - an appointment with a GP in the days after leaving hospital.
"While hindsight and the knowledge of what happened to Mark less than 20 hours after he left the hospital makes us question the wisdom in giving him such a large supply of medication on discharge, I accept that the decision to do so was properly informed and appropriate in all of the circumstances at the time," Coroner Beattie said.
Offering independent medical opinion, Sydney consultant psychiatrist Michael Robertson told the inquest Wollongong's Dr Anju Abujam, had been "meticulous" in caring for Mr Gleeson.
The psychiatric registrar had gone "well beyond the call of duty" by questioning Mr Gleeson's decision to leave hospital and offering to call his family or arrange his return to Oolong House - both proposals he refused.
Mr Gleeson was hospitalised with $120 in his wallet, but had just $1.25 when his body was found - a possible indicator of the quantity of alcohol he consumed.
He was discharged from Wollongong with four different kinds of medication - 81 tablets in all.
The inquest heard Mr Gleeson had been sober for six weeks before he overdosed, ending a life in which mental health units - but also family, and laughs - had featured large.
Mr Gleeson's mother, Janice Gleeson, told the inquest her son had a wonderful sense of humour and had enjoyed bodyboarding and the outdoors.
With Mr Gleeson's father Ivor and his brother Warren, she said her son loved his family - especially his son, Connor - and, with his "heart of a giant", got on well with children generally.
"Basically he was a big kid himself," Mrs Gleeson said.
"He is missed and loved by each and every one of us."
Mr Gleeson's death has prompted changes at Oolong House, where staff will now contact family members when their relative leaves the facility, providing the relative consents.
Clinicians at Wollongong Hospital were restricted by privacy legislation, and duties of doctor-patient confidentiality, when they abided by Mr Gleeson's repeated instructions not to tell his family he had been discharged.
Coroner Beattie said it was appropriate, though tragic, that his family was not informed.