Kelvin Forrest, 53

Kelvin, 53, had Down syndrome and dementia. He was effectively a “social admission” at Byron Central Hospital while appropriate disability supports and discharge arrangements were being sought. Despite known wandering behaviour, he accessed an unsafe area and fell from height, dying from his injuries.

The inquest specifically examined NDIS provision and discharge planning. The coroner described Kelvin’s hospitalisation as inextricably connected with the search for adequate support, and his death as a wholly preventable tragedy — although the immediate preventable failure was inadequate hospital supervision and management of his wandering risk, rather than an explicit finding that the NDIA caused his death.