Man who died after leaving NSW hospital 'overlooked' by public guardian, inquest hears

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A man who died from internal bleeding after discharging himself from a New South Wales hospital was "overlooked" by the public guardian, an inquest has heard.
Raymond Wheatley was found dead in his Wagga Wagga home on December 6, 2021, a week after he was admitted to the local hospital with low haemoglobin levels, anaemia and internal bleeding.
The 54-year-old was given three blood transfusions before he felt better and wanted to go home to get cigarettes and a jacket.
The three-day inquest heard that in 2020 Mr Wheatley was put under a public guardianship appointed by the NSW Civil and Administrative Tribunal (NCAT) to make lifestyle, health and medical decisions for him.
On Wednesday the inquest heard from Vicky Elliott, who was the NSW Public Guardian's southern regional manager at the time of Mr Wheatley's death.
She told the inquest that Mr Wheatley had been assigned a guardian in 2020, but when that person changed roles a year later his case was not reassigned and was instead managed by the team as a whole.
Counsel assisting the coroner, Gillian Mahony, told the inquest the public guardian made key decisions about Mr Wheatley's life, including consenting to a key-box and key being outside his home and NDIS requests, without consulting him "in respect to any of those decisions".
Ms Mahony asked Ms Elliot if there was a communication breakdown with Mr Wheatley, given the "minimum attention" he received.
"It's possible his file could have been overlooked or there was some miscommunication," Ms Elliot responded.
Earlier the inquest heard from Louise Gabauer, who was the emergency registrar at Wagga Wagga Base Hospital at the time.
She told the inquest she called the public guardian to discuss whether the hospital had "any provision to detain" Mr Wheatley.
Dr Gabauer was told that the public guardian and hospital staff did not have the right to keep him there without his consent.
The inquest also heard that hospital staff contacted NCAT for a review of Mr Wheatley's public guardianship, but that did not happen.
Dr Gabauer said she conducted what she called a "capacity assessment" while speaking to Mr Wheatley outside the hospital.
She told the inquest she believed he was "lucid" and "logical", but told Mr Wheatley it was essential he return to hospital.
"There's a chance that you could die if you leave," the inquest heard she told him.
The public guardian formerly assigned directly to Mr Wheatley and two other witnesses were expected at the inquest today.
Family statements were also expected to be tendered, but Ms Mahony told the inquest more time was needed before other witnesses were heard from.
The inquest has adjourned until August.