A man who died from internal bleeding after discharging himself from a New South Wales hospital was “overlooked” by his public guardian, an inquest has heard. Raymond Wheatley, 54, was found dead in his Wagga Wagga home on December 6, 2021, a week after being admitted to the local hospital with low haemoglobin levels, anaemia, and internal bleeding.
During his hospital stay, Wheatley received three blood transfusions, which improved his condition. He expressed a desire to go home to retrieve cigarettes and a jacket. The inquest, which spanned three days, revealed that Wheatley had been under public guardianship since 2020, a decision made by the NSW Civil and Administrative Tribunal (NCAT) to oversee his lifestyle, health, and medical decisions.
Guardianship Oversight and Communication Breakdown
On Wednesday, the inquest heard from Vicky Elliott, the NSW Public Guardian’s southern regional manager at the time of Wheatley’s death. Elliott explained that although Wheatley was assigned a guardian in 2020, the case was not reassigned when the guardian changed roles a year later, leaving the team to manage it collectively.
Gillian Mahony, counsel assisting the coroner, highlighted that the public guardian made crucial decisions about Wheatley’s life, such as consenting to a key-box outside his home and handling NDIS requests, without consulting him. Mahony questioned Elliott about the apparent lack of communication, suggesting that Wheatley’s file may have been “overlooked” or suffered from “miscommunication.”
“It’s possible his file could have been overlooked or there was some miscommunication,” Elliott responded.
Hospital’s Role and Wheatley’s Mental State
The inquest also heard from Louise Gabauer, an emergency registrar at Wagga Wagga Base Hospital during Wheatley’s admission. Gabauer testified that she contacted the public guardian to discuss the hospital’s ability to detain Wheatley, only to be informed that neither the guardian nor the hospital staff had the authority to do so without his consent.
Despite efforts by the hospital staff to contact NCAT for a review of Wheatley’s public guardianship, no action was taken. Gabauer conducted a “capacity assessment” and determined that Wheatley was “lucid” and “logical,” though she warned him of the potential fatal consequences of leaving the hospital.
“There’s a chance that you could die if you leave,” the inquest heard she told him.
Implications and Next Steps
The inquest is expected to hear from the public guardian previously assigned directly to Wheatley and two other witnesses. Family statements are also anticipated, although Mahony indicated that more time is needed before these testimonies are presented. The inquest has been adjourned until August.
This case underscores significant issues within the public guardianship system, particularly concerning continuity of care and communication. Experts suggest that systemic improvements are necessary to prevent similar tragedies. The NSW government may face pressure to review and possibly reform the guardianship process to ensure more robust oversight and accountability.
As the inquest continues, it remains to be seen how these findings will impact public policy and whether they will lead to changes in the management of vulnerable individuals under guardianship in New South Wales.
