CITATION: Inquest into the death of David William Mather [2005] NTMC002

TITLE OF COURT: Coroner’s Court


FILE NO(s): D0119/2004

DELIVERED ON: 18 January 2006


HEARING DATE(s): 5, 6 December 2005

FINDING OF: Greg Cavanagh SM

Unexpected death, Missing patient, Hospital “Absconding Patient Policy”, Recommendation


Ms Lyn McDade
Dept. Health & Comm.: Mr Kelvin Currie

Judgment category classification: B
Judgement ID number: [2006]NTMC 002
Number of paragraphs: 16
Number of pages: 18


No. D0119/2004
In the matter of an Inquest into the death of

BETWEEN 4th October 2003 and 14 July 2004


(Delivered 18 January 2006)

Mr Greg Cavanagh SM:

1. David William Mather (hereinafter called the deceased) died sometime between 4-5 October 2003 in bushland adjacent to Royal Darwin Hospital (RDH).

2. A public Inquest into his death pursuant to section 15 of the Coroner's Act (the “Act”) was held in Darwin on 5 and 6 December 2005. Counsel Assisting me was Ms Lyn McDade. The family of the deceased was not represented. The Department of Health and Community Services was represented by Mr Currie. I thank Counsel for their assistance.

3. Five witnesses were called to give evidence at the Inquest. Those witnesses were; Detective Senior Constable Isobel Cummins a member of the Northern Territory Police Service, who investigated the death of the deceased and produced a thorough and comprehensive report that was tendered at the inquest. Senior Constable Kaye Pemberton, also a member of the Northern Territory Police Service who is currently serving as the police liaison officer at Royal Darwin Hospital. (“RDH”). Ellissa Roland, a nurse, gave evidence by video link from Bendigo. Dr Rachel Glasson gave evidence by video link from Canberra. Nursing Director Sharon Sykes also gave evidence. In addition to their evidence I also admitted into evidence a number of statements from other witnesses, the post mortem report, and the deceased's medical records.


(i) The deceased was David William Mather, a Caucasian male born on 23 September 1936 at Greymouth, New Zealand.

(ii) The deceased died sometime between 4-5 October 2003 in bushland adjacent to RDH.

(iii) The cause of death could not be determined by post mortem examination.

(iv) The particulars required to register the death are:

a. The deceased was male

b. The deceased was David William Mather.

c. The death was reported to the Coroner.

d. The cause of death could not be confirmed by post mortem examination.

e. The cause of death is undetermined.

f. The pathologist viewed skeletal remains after death.

g. The pathologist was Dr David Ransom.

h The father of the deceased was David William Mather.
and the mother of the deceased was Violet Elizabeth Mather.

i. The usual place of residence of the deceased was in the "long grass" Darwin.

j. The deceased was unemployed.


4. The deceased was a well known itinerant (otherwise known in Darwin as a "long grasser") who lived in and about Darwin city. He was often seen in the city pushing a shopping trolley containing his personal effects. He had an extensive medical history and had been hospitalised on a number of occasions, as evidenced by his medical records which were tendered to me.

5. In May 2003, the deceased was admitted to RDH with injuries sustained from an assault. Amongst other injuries he had fractures to his left and right humerus. He remained in hospital for some weeks. After discharge he returned to his itinerant lifestyle.

6. On 29 September 2003, the deceased was found by police on McMillans Road, Jingili about 10.00 pm complaining of a painful upper left arm. He was intoxicated and appeared to have fallen trying to push his shopping trolley up the kerb. An ambulance was called and the deceased was conveyed to Accident and Emergency RDH. At RDH he was seen by Dr Shepherd a resident medical officer. Dr Shepherd after examining the deceased noted that his main issues were a displaced compound fracture of the left humerus, homelessness and a history of hernia. The deceased's vital observations were assessed as stable and within normal limits.

7. The deceased was administered morphine for pain, given a tetanus shot, commenced on intravenous antibiotics and referred to the Orthopaedic Registrar for admission and further treatment. He was admitted to ward 3A under the care of Dr Mehta. His treatment was conservative and involved placing his fractured upper arm in a humeral brace to stabilise the fracture, and the continuation of intravenous antibiotics with analgesia for pain.

8. The deceased was visited daily by the orthopaedic team and his treatment monitored. He was a reluctant patient and often removed the brace and intravenous drip and left the ward.

9. Sometime after 10.30 am on 4 October the deceased left ward 3A wearing his hospital pyjamas. He did not return. He left behind his arm brace, clothes and several hundred dollars in cash. The cash was held by hospital security and not by ward staff. Registered Nurse Elissa Roland noted the deceased's long absence from the ward at about 2020hrs on 4 October 2003. She ordered a search of the ward and the front of the hospital. The deceased was not found. Nurse Roland was aware of the RDH

“Absconding Patients Policy” (Annexure 1 & 2) and in compliance with that policy she contacted the duty Registrar Dr Rachel Glasson and reported the deceased's absence from the ward. In her evidence she said (T33 – T37):

“But you were working the evening shift on 4 October?---That's right.

What time does the evening shift commence?---At 1 o'clock in Darwin, yes, 1 o'clock to 9:30.

In the afternoon?---In the afternoon until 9:30 at night.

So is it the case when you came on to the ward on that day, do you remember seeing David Mather about the ward?---No. I don't recall.

Can you recall seeing him at all after you commenced duty on shift?---No.

Did you make any enquiry of anybody else during the course of that shift as to whether they'd seen David Mather?---From my notes I assume I was in charge of the shift.

On that basis I am aware of everything that's going on but I often don't hear about things unless something is wrong. So no one had actually said to me, no, he's not here.

No one had made a comment about it.

When was it then that you became aware he had been absent from his bed or the ward for over four hours?---The nurse - and I don't recall who that was, said to me, he hasn't been seen for over four hours. So it would have been maybe around the 8 o'clock mark. What time did I write my note?
8 o'clock, 2000 hours?---Yes, it would have been around that time.

But you'd been on duty that day from 1 o'clock in the afternoon through to 8 o'clock?---That's right.

And you can't recall seeing him at all?---No.

And you can't recall whether or not anyone came to you and said, look, he's not here?---No.

To the best of your recollection someone came to you about 8 o'clock and said, look, I haven't seen him?---Yes, that's right.

What did you then do upon being informed that David Mather hadn't been seen for over four hours?---As per the absconding policy I phoned Rachel Glasson, the orthopaedic registrar who was on call, informed her of the situation and we decided, between the two of us decided that it didn't warrant involving the police. I also informed the nurse in charge of the hospital.

Nursing resource consultant?---Yes, that's the one, nursing resource consultant.

Tell me, when you contacted Dr Glasson can you recall what it was you said to her?---No.

THE CORONER: Can you recall anything she said to you?---No, I can't, it's two years ago I can't recall the conversation.

MS McDADE: When you spoke with Dr Glasson to indicate that Mr Mather was not present on the ward and you discussed him, I take it. Did you discuss his general condition, do you recall?---I don't recall, we probably would have but I'd be guessing.

Tell me, do you recall having access at all to his inpatient notes at the time?---Yes, I would have. I would have had, yes, access to them.

Do you recall being aware of his condition, in a medical sense, at the time you were speaking to Dr Glasson?---His presenting condition or his previous conditions?

No, the condition he had at the time?---Yes, he came in for a manipulation - a non-union of a fracture of his humerus.

When you spoke to Dr Glasson I take it she was not on the ward?---No, it was by phone.

So Dr Glasson couldn't - did Dr Glasson, to your knowledge, have access to his inpatient medical records at the time?---To my knowledge no because the notes would have been on the ward with me.

The notes would have been with you?---That's right.

You in fact made an entry in those notes, didn't you?---Yes.

And you made that entry and I'm going to read it to you?---Okay.

This is made at 2000 hours, 8 o'clock in the evening on 4/10. 'Nursing. Patient not seen for over four hours on ward. Contacted ortho registrar Rachel Glasson who did not want police called'. Then it has got 'NRC notified and patient discharged'. There's another entry made, 'Clothes and other belongings plus two security keys all in security office', and you've signed both of those entries?---Right.

Now, you've indicated to us that you and the good Dr Glasson discussed Mr Mather together to make a decision not to tell the police?---Yes.

At the time that you had that discussion were you aware of the hospital's absconding patients policy?---Yes.

Were you aware of what was required in relation to a patient such as Mr Mather who had absconded?---Yes.

Can you tell us why you made the determination in his case not to inform the police?---Stating again it wasn't my sole decision, it was in discussion with Rachel, I based it on the fact that he was not acutely ill. He was not under the Communicable Disease Act or the Mental Health Act, he wasn't a minor and he wasn't a harm to himself or to others. That was the criteria that I was aware of from the policy and he didn't fit any of those things, so on that basis he was not followed up by the police.

THE CORONER: Nurse, I don't know whether you are but you don't have to be defensive about this, in fact what you've just told me is perfectly reasonable give what was in the policy. I think we're going to have a little bit of a go at the policy but certainly what you did was in accordance with the policy. I can see that you're a little bit defensive about it, you don't have to be, okay?---I'm just nervous, just nervous.

Okay, just relax.

MS McDADE: You knew or you knew of and had had some involvement with the treatment of Mr Mather whilst he was in hospital on this occasion, haven't you?---On this occasion he was in for, I think only two or three days.

He came in on 30 September, yes, he was in about four days?---Four days. I didn't - I don't think I looked after him individually at admission but I had had dealings with him on his previous admission, I think it was September, end of May of 2003, yes.

And that's when he came in when he had bilateral breaks to the humerus bones?---That's right.

Indeed, you were also aware that he had a hernia condition?---I certainly was, yes.

Were you aware at the time that his treating orthopaedic team was headed up by Dr Mehta?---At the time I would have been aware of that.

In fact Dr Glasson was not a member of that team?---No, she was not one of his registrars.

So Dr Glasson, to your knowledge, wouldn’t have known David Mather at all?---To my knowledge, however, all the orthopaedic registrars have some knowledge of the patients on the ward because they do the weekend rounds and they do the after hours rounds and any problems after hours goes to the registrar on call as opposed to the team that is involved with the patient's care.

So it's the registrar on call that has to make the decision?---That's right.

Based on whatever knowledge they may have of that patient?---That's right.

You'd agree with me they'd have greater knowledge of patients that their team was treating?---Absolutely, yes.

And they'd just be gleaning knowledge about the others, as a consequence of their after hours duties?---Absolutely, yes.

As a consequence of that discussion with Dr Glasson the police weren't informed and David Mather was discharged in absentia, wasn't he?---Yes, that's right.

And that again accorded with the policy?---That's right.

Because he had to be discharged effectively to free up the bed, didn't he?---Yes.

The situation was that he was occupying an acute orthopaedic bed?---Yes.

And in your view as a nurse did he require being in an acute orthopaedic bed on 4 October?---Yes, he did but you need to be in the bed to be getting the care that you need, that you should be receiving. That's the tough one, that's the fine line - not the fine line but that's where it becomes difficult. If you're going to be there, yes, you probably deserve it - not deserve it but that's fair enough but if you're not going to be there, then someone who is possibly more acutely ill could be using that bed.

When you say not there. Was it the case that Mr Mather would leave his bed space on a regular basis?---Yes, but he would frequently come back for meals and this is based on his previous admission that I'm basing that opinion on.

He wasn't a recidivist absconder was he? He didn't always abscond, in the sense of go away and not come back for days and then return?---No, no.

When you say he left his bed space, what you're saying is he might go away for a couple of hours?---Yes.

But come back?---That's right.

So would it be the case that it was not unusual that if you looked at his bed space you wouldn't see David Mather during the course of a shift?---That's right, you may miss him when he comes back in.”

10. Dr Glasson was also aware of the policy and she formed the view that the deceased's absence did not warrant further action, in particular his absence did not require a report to the police. In her evidence the Doctor said the following (T42 – T44):

“Can you tell us why, I know you've referred to it in your statement, you determined that the police did not need to be informed about Mr Mather not being in the ward?---The first point would be his medical condition and he - you need to call - get patients back or get them back if they're suffering any acute medical illness that's life threatening or that will worsen without treatment and his condition was not in that category. So he had a refractory fracture of his humerus, as I recollect, so that didn't require that he be summonsed back. To the best of my knowledge he was not acutely mentally unwell, although there may be some question about his cognitive abilities or his actual - I think that there may have been a question about some cognitive impairment as a result of his alcohol use in the past and that he was itinerant and I knew that he was itinerant. He wasn't a danger to himself or others so he wasn't homicidal or suicidal and he didn't have a life threatening illness. As to whether he was mentally unwell, I didn't think he was acutely mentally unwell and he wasn't incompetent. So on those grounds he didn't fit the category - any of the categories which mean patients need to be summoned by the police.

So you made that call, that the police didn't need to be informed?---Yes, based on the knowledge of his present medical condition and his mental condition, as far as I knew.

And that was in accordance with the then existing hospital policy in relation to absconding patients?---Correct.

Can I just ask you to opine for the moment, you're quite aware of what that policy says. For instance, if it's a life threatening illness call them back, if they're under a mental health order, if they're under notifiable diseases, etcetera and I think there was a third category?---Homicidal or suicidal.

Danger of causing injury to themselves or others?---Exactly.

In your opinion, given your experience at Royal Darwin Hospital and the number of absconders and the situation and your knowledge of Mr Mather, do you think that policy is too prescriptive? Should it have had facility for people in Mr Mather's situation, being aged, homeless, some cognitive impairment, to be reported, do you think? I know I'm asking you in hindsight?---My opinion?

Yes, your opinion?---In an ideal world it would be good if we could take care of everybody who had no home to go to and was suffering the effects of long term alcohol use, that would be nice. But compelling people - it's one matter to want to do the best thing for everybody and it's another matter to actually compel people to stay in hospital. I actually also knew from the notes that Mr Mather had previously refused housing assistance and had absconded in the past. So I think that we can't force people to take our help unless they're mentally ill, homicidal, suicidal or they're going to die unless you treat them. Certainly if people are sick and are going to die I generally don't let them leave hospital but I don't think you can compel people to - you can offer your help but I don't think you can make them take it all the time and I don't think you should be allowed to enforce that otherwise you'd have a lot of homeless people in hospital or shut up somewhere not at liberty.

THE CORONER: I take your point, doctor. This is Greg Cavanagh, the Coroner. The problem might not be a decision that was made by you and the nurse on that day, is what do you do where the patient doesn't come back. He's only in his pyjamas or the like, he has left nearly $1000 of cash and other personal items in the hospital plus some aids to do with his broken arm. It's suggestive that someone should have maybe woken up and wondered where he was?---Okay, my role was to make a decision based on medical and mental health issues, I had no idea that he'd left $1000 behind, I didn't know that. So my decision was made on the basis of what I was informed and what I knew, not on that basis.

Doctor, I accept all that, I wasn't having a go at you about your decision on that day but we did ask you about your opinions and I just wanted to expand the scenario for you, as I have, and ask you for comment about that scenario?---Well that certainly changes things because it seems like he - if he was intending to just abscond and not come back he would have taken his stuff with him you would have thought, so I think that does change things significantly, yes. So a search could be made, yes.

You also said that you had several times previously been in a situation where you had to make a decision as to whether an absconder should be reported to the police. I think you mentioned five times?---That's an estimate.

Of those estimated times did you in fact report people to the police or not?---Yes.”

The deceased was discharged in absentia and no further inquiries were made.

11. Given the deceased's personal circumstances, homelessness, no family in Australia and the fact that his hospital records recorded his deceased brother as his next of kin, no one became concerned when the deceased disappeared.

12. It is apparent that the deceased left the hospital of his own accord sometime on 4 October 2003 and walked to bushland near the helipad. Given that he left his money, arm brace and other personal effects it is likely that he intended to return to the hospital. The deceased's skeletal remains were found by a hospital visitor on 13 July 2004. Police searched the bushland and recovered the deceased's skeletal remains. Dr Ransom a highly qualified Forensic pathologist examined the remains but was unable to determine the cause of death. Detective Senior Constable Isobel Cummins conducted an investigation on my behalf and found no evidence to suggest that the deceased had been the victim of foul play. It is likely that the deceased perished from exposure and dehydration.

13. The identity of the remains was initially unknown. The deceased may not have been identified but for the efforts of Detective Senior Constable Cummins, Senior Constable Kaye Pemberton and Caroline Adam, (Dr Notoras' personal assistant) all of whom spent hours going through hospital records in an attempt to identify the remains.. Thanks to their efforts the skeletal remains were identified. The identity of the skeletal remains was confirmed by DNA testing of the right femur bone with blood extracted from the humeral brace labelled David Mather which the deceased had left at the hospital. I refer to the evidence of Senior Constable Kaye Pemberton (T19 – T20):

“MS McDADE: Now, you've taken a particular interest in relation to David Mather, haven't you?---Yes.

Is it the fact that you were aware of his attendance at the hospital in September?---I don't know if I'm aware of his attendance in September, but I know David Mather because he was in hospital for quite a long time when he had both broken femurs - - -

Bilateral humerus?---And in relation to conducting the searches and trying to identify who the bones belonged to which, you know, we had to create computer programs to do searches and that sort of stuff. And in the end we had to go through every adult male admission over an 18 month period.

Who did that?---Caroline Adam, Len Notaras' personal assistant and myself actually went through the list from the hospital and it was extensive, like, there was something like 18,000 males came up and we were going through the list one by one, had they re-presented, you know, getting the list down. It got to one stage where I actually went for a search up where the bones were found with security and we searched far and wide hoping to find a name tag because that was never found. I thought, please, let's just find a name tag. It wasn't until 12 November, and that's when I contacted the detective, where we were sitting in the office and David Mather's name came up and as soon as I said the name David Mather, I said that's him. Because I knew him and I knew that he had multiple injuries. I hadn't seen him for a while and he sort of fit the criteria of not having any family - - -

THE CORONER: Was this before the DNA?---Yes, this is how we came up to prepare his DNA. I came up with the name, I got the medical file. I'd also previously been spoken to by security that Mr Mather had left property and cash there and I hadn't put two and two together at that stage and I'd actually said, look, get the money to registry and we'll contact the police and let them know to look for Mr Mather and that sort of stuff and I don't recall if I actually contacted the patrols in Darwin and said, look, if you happen to see the trolley man around can you let him know he has got some property out at the hospital.

That was his nickname, wasn't it?---Yes, the trolley man, yes. So I went to security as soon as I got the name and found - I said, I want to see what property he has left here and found that his (inaudible) there was blood in it and I let the detective know that found that and I took the brace out to forensic services to get some DNA on. Then I also got the medical file down to the mortuary technicians and going from the file and looking at the previous injuries that he had they were matching with the injuries to his bones. So we were pretty confident it was Mr Mather at that stage but it wasn't until December that the DNA confirmed definitely.

MS McDADE: And that's how eventually he was identified?---Yes.”

14. RDH has developed a policy to manage absconding patients. The evidence of Nursing Director Sharon Sykes revealed that a significant number of patients leave the hospital prior to formal discharge; and this is a real and continuing problem for the hospital. Prior to the policy being developed the absence of a patient was referred to police. That placed a burden on police resources. I refer to her evidence (T45 – T46):

“Was it the case that prior to policies being developed in relation to this that every time a patient left the hospital prior to formal discharge the police were informed?---Pretty much so, yes.

So I understand that there are a number of people who attend Royal Darwin Hospital who do discharge themselves, if I can put it in those terms?---Yes, they do and the majority of them are ready for discharge or quite well to go but there are a small number that really do need follow up.

So prior to the advent of the absconding patients policy you would report everyone?---We were reporting everyone and we had feedback from the police that the follow up of all of the people really it made it less thorough for each person and it wasn't their best use of time. So by narrowing it down to the people that we really needed to report they were actually able to do a more thorough follow up.

It was a bit like crying wolf wasn't it?---Yes.

And particularly so when you tell us in your statement that up to 730 patients between July 2004 and June 2005 could be classified as absconding patients?---Yes, that was the data that the computer gave us.

Now, can you tell me whether or not you've got any data in relation to 2003 and 2004? Do you think that figure is pretty indicative of the years past?---Yes I think so. There is data available but I didn't get it.

But you wouldn't be surprised if that was indicative of the numbers that had been - - - ?---I've been working at Royal Darwin Hospital for 10 years and it seems to have been an ongoing state.”

15. The policy is about to be reviewed and I discussed with Nurse Sykes at the Inquest how the revised policy might include further checks about patients so that the medical staff making the decision not to inform police about a patient's prolonged absence do so with as much information as possible. I refer to that exchange (T48 – T50):

“THE CORONER: Well, what about some follow up? You make a decision based on the formula that he doesn't need to be reported but if there was some caveat to the prescription about the man's circumstance. Lets put aside this bloke?---Yes.

Imagine a patient who doesn't fall strictly within the criteria and hasn't come back but he has left in pyjamas, leaving clothes there. He has left without medical aids for mobility, he has left without his personal effects and money, amounting to several hundred dollars which is a lot of money and doesn't come back. That kind of description is not suggestive of a bloke who is not going to come back, is it?---Yes.

So when he doesn't come back that would, from a commonsense point of view, should be an alarm signal to somebody. Do you agree with all that?---I do and that's where I make the comment, it's up to the clinicians, the person who knows them.

That may be right but they're not to know all of those things?---Yes.

At the time they make the call. They don't know what is in the security box, for example?---Yes.

That's not in the hospital notes. They don't know sometimes exactly what state he left in, pyjamas or clothes They don't know what other personal effects were taken or not taken sometimes. Perhaps there should be some further inquiry or caveat or qualification mandated to the prescription, to the formula, don't you think?---Yes, I think that that's a valid point.

To cover this kind of thing?---Absolutely.

Like, when you make your decision on the prescription please make it on an informed basis of things like what did he leave, did he leave his clothes and only go in pyjamas with no shoes. Sometimes they do because they're only going to slip down and have a smoke but, gee, he hasn't come back. Do you agree with all that?---I agree. Yes, I do, I do.

MS McDADE: As I understand it though, even in the event that police are called the follow up in relation to the police is effectively done by the ward, is that right? They maintain the notes?---The ward maintain the notes but we work in very closely with the hospital police person, Kaye Pemberton, and she follows up with people as well from the police side of things.

But is it contemplated within your review to look at what happens, not only in instances where the police are called and what the Coroner has just gone through with you, but in instances where the police are called, who will be responsible for that follow up?---Yes, it's certainly one of those things that we need to really clarify and set the responsibility properly so that that does occur.

THE CORONER: Yes, well, it seems to me that what is emerging is two areas, that is to say, to qualify the prescription formula, do it from an informed basis of what was left, what wasn't left, what did he wear when he left and is there any personal effects in the security box downstairs. So when you make the decision based upon the formula you do it from an informed basis about the person. Secondly, where you think he might come back after missing a meal or he has gone down for a drink or a smoke that in the next day or two a follow up be made. There would be room for a follow up to be made where the person has only left with pyjamas and didn't pick up his money. So if you don't call the police on that basis there's a follow up tick some days later, do you think that would work?---I think it's practical, yes. I think if somebody, we are concerned that somebody has gone and they're not in the categories of guardianship, mental health and notifiable, our powers to bring them back, you know, do we just check that they're okay, that sort of guardianship stuff.

I'm not suggesting that you have the power to bring them back or do anything but further consideration, especially when they haven't come back when they left in pyjamas, might see a change to the initial decision not to report it to police?---Yes.

That's what I'm suggesting?---Point taken, yes.


THE CORONER: Now, Mr Curry, I think that what has fallen from me in the last few minutes, you can see the way I'm thinking. Have a think about it and Ms McDade have a think about it. I don't think that there's anything that's going to be super critical of the hospital, it's just a matter of perhaps qualifying the formula to pick up someone like the deceased.

MR CURRY: Well, that's certainly, I think in the mind of everyone, it's just how it can be done.

THE CORONER: Yes. It has just occurred to me, off the top of my head just then that, you know, those people in the deceased's category there may need to be some fall back decision by the hospital administration to have a look where there's an initial decision not to report. Although there may not have to be any fall back, if when the decision is made not to report it, it's on a fully informed basis. It seems to me, from what Dr Glasson was saying, that if she had been aware, fully aware of things like that he left personal effects, he did only go ion his pyjamas and he has left his money there, she might have made a different decision.

MR CURRY: It could very well be that perhaps the nurse on the ward could check those things before contacting - - -

THE CORONER: Yes, I don't think it would be difficult, it's just an extra two or three checks before you go to the prescribed criteria. So it's not just a matter of looking at the medical notes, but ringing up administration, has he got anything in the security box, what is left? He didn't take the key and he has got some clothes here and he has left his thing that holds his arm up. Who knows?”


16. The deceased died whilst an inpatient at RDH. He left the hospital without being formally discharged. That is he absconded and fell to be dealt with by hospital staff in accordance with the extant policy dealing with absconding patients. I am satisfied on the evidence available that staff involved with the deceased acted in accordance with the RDH policy relating to absconding patients, and that the deceased's disappearance did not require a report to police. However, as I indicated at the Inquest, I RECOMMEND that RDH consider some changes to the policy so that a decision not to report a missing patient to police is made with as much information about the patient as possible. The evidence in relation to the deceased in this case revealed that there was relevant information held by the hospital but not made available to the decision maker. I also suggest that the policy should include persons who are subject to Adult Guardianship orders.

Dated this 18th day of January 2006.