Inquest into the death of David Mather

Contributing factors

• homelessness and lack of fixed abode
• absconding from hospital without formal discharge
• incomplete information available to decision-maker regarding patient circumstances
• policy did not require notification to police for patient in deceased's circumstances
• decision-maker unaware of items left behind in security and cash
• decision-maker unaware patient had left in pyjamas only

Coroner's recommendations

1. RDH should consider changes to the Absconding Patients Policy so that decisions not to report a missing patient to police are made with as much information about the patient as possible
2. Before deciding not to report a missing patient to police, staff should check what items the patient left behind (clothing, personal effects, money held in security, medical aids such as arm braces) and what state they left in (pyjamas only vs. dressed)
3. The policy should include provision for follow-up checks within one or two days for patients who leave in circumstances suggestive of intent to return (e.g., left in pyjamas, left personal effects, left money)
4. The policy should be expanded to include patients subject to Adult Guardianship orders
5. The hospital should clarify responsibility for follow-up when police are contacted regarding a missing patient