Coroner's Finding: Fowles, Wayne Lincoln

59y · Male·hanging

A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency unit then transitioned to the open ward after clinical review. Despite 30-minute observations initiated due to concerning night-time behaviour, he absconded on 19 October 2021 and died by hanging two days later. The coroner found the clinical management appropriate, the ITO properly imposed, visual observations compliant with procedure, and the subsequent police search competent and thorough. There was nothing in his presentation that should have indicated intention to abscond or self-harm. The death was not preventable.