Roger Frederick Schnelle died on April 30, 2021 from self-inflicted head injuries, 20 days after he was admitted as an involuntary patient to Albury Wodonga Health's high-dependency mental health unit.
Delivering her findings on Thursday in Albury, coroner Erin Kennedy said the 63-year-old accountant's "ferocious and sudden" mental deterioration came as a shock to all who knew him.
Mr Schnelle's wife Yvonne watched on via a live-stream, as the coroner recommended risk assessment tools for the chief executive of Albury Wodonga Health to implement.
Although the findings "cannot alleviate their feelings of loss and grief", the coroner applauded the family's preparedness to contribute to improvements in the health system.
Mr Schnelle had sustained multiple skull fractures and a significant brain haemorrhage when he was taken to the intensive care unit.
Two days later, his injuries were labelled as non-survivable and he was taken off life support.
"His family took the steps of taking him to hospital to try and protect him," she said.
"They put him in the safest place he could be, and yet he still could not be protected."
Ms Kennedy noted the man was a very successful, family-orientated and very high-functioning person before things suddenly changed.
Mrs Schnelle previously described her late husband as someone who was intelligent, considerate and generous in all aspects of his life.
"He was compassionate and knew how to make people feel better about themselves, especially those that he loved," she said.
"He liked to give people joy."
Mr Schnelle had not suffered from any major mental health issues before his last few months, the coroner noted, aside from some minor anxiety in enclosed spaces.
Ms Kennedy recommended the implementation of an electronic medical record across the NSW-Victorian border for mental health services and a review to ensure service policies are aligned in both states.
She said tools that focus on assessment and management of risk are required to consider risk indicator factors associated with increased suicidal behaviour.
Staff induction processes should also clearly identify relevant policy and practices in relation to the assessment, formulation and management of risk documentation and patient observations, she said.
Lifeline 13 11 14
beyondblue 1300 22 4636
20°C