Finding into death of John Bernard Tuffy

48y · Male·drowning

John Tuffy, 48, died by drowning after absconding from a mental health waiting room at Bayview House while awaiting transfer to hospital. He had returned from Ireland with acute psychosis triggered by his mother's sudden death, a distressing plane incident, and sleep deprivation. Despite recognition of his disorientation and risk of accidental harm, he was left in a busy, noisy shared waiting room with only administrative staff awareness of his need for supervision. Clinical staff checked on him intermittently but no direct observation occurred. He left saying he needed air and subsequently entered the sea. The coroner found supervision inadequate given documented risks, though staff acknowledged the need for closer observation. Peninsula Health implemented immediate changes: transferring waiting patients to the ED at Frankston Hospital for better supervision, and modifying facilities to separate transferring patients. The death highlights gaps in observation protocols for disoriented psychiatric patients awaiting transfer.