The brother of Kelvin Forrest, who died after falling from the roof of Byron Central Hospital, has told an inquest that authorities entrusted with the disabled man's care "failed to act".
On the final day of a five-day inquest, John Forrest said his family just wanted people to "recognise the deficiencies" that may have contributed to his brother's death.
Coroner Harriet Grahame said the proceedings were held out of respect for Mr Forrest's life and to ensure such incidents could not happen again.
The Coroner said she had been "profoundly moved" by the love and support given to Mr Forrest to allow him to live his best life.
With the support of his family and carers, Mr Forrest had lived independently in a unit in Byron Bay, worked at Byron Bay Herb Nursery, volunteered with organisations including Liberation Larder and Meals on Wheels, and embraced supported activities including surfing, tenpin bowling and horse riding.
Door to balcony left unlocked
Mr Forrest died after falling from the hospital roof into the loading dock below. He was found by security staff at 5am on July 28, 2018.
The 53-year-old had been hospitalised 11 days before his death after a carer found him on the floor of his Byron Bay home in pain and hypothermic.
The inquest heard Mr Forrest had gained access to the roof through a glass door onto a balcony that had been left unlocked to prevent another patient with behavioural issues from breaking it.
During the hearing, the court heard evidence about Mr Forrest's propensity to wander and questions were raised about the appropriateness of placing patients with competing needs in the same ward.
Counsel assisting the coroner Ragni Mathur questioned several nurse witnesses about a decision to not provide Mr Forrest with one-on-one supervision in the 24 hours before he died, despite wandering onto a busy road outside the hospital days earlier.
Disability funding frustrations
At the time of Mr Forrest's death, John Forrest had been seeking an increase in funding from the National Disability Insurance Scheme to support the escalating needs of his brother, who had been given a provisional diagnosis of dementia.
United Disability Care support coordinator Angela Hartley said while she was initially trying to get his funding increased, she did not submit quarterly monitoring reports to the National Disability Insurance Agency (NDIA) because none had been created when she started the job and she had been told by NDIA staff they did not always read those reports.
Coroner Grahame said, if true, the allegation would be "pretty shocking".
The court heard that the family's efforts to get 24/7 care for Mr Forrest would have been assisted by getting specialist reports from an occupational therapist and a geriatrician.
John Forrest said he grew frustrated with the process and that each time he submitted documents for the funding application, he was told about a new piece of evidence he would have to find.
NDIA state manager Lisa Short told the inquest the application could have been dealt with quicker if the specialist reports had been prepared in a more timely way.
Ms Short said it was well known the reports were required for a funding increase.
The Coroner will hand down her findings on February 25 next year.
