Lynn Desmond Ernest Church had a history of psychiatric illness and had tried to take his own life twice before being placed in an open ward at a mental health facility.
Despite being observed by nurses every 15 minutes, the 65-year-old managed to make them think he was sleeping soundly in his bed by rolling up towels, blankets and a beanie.
Meanwhile, he entered his ensuite bathroom where he was later found dead from asphyxia.
The West Australian coroner is now investigating the quality of the supervision, treatment and care provided to Mr Church, who was an involuntary patient at the Joondalup Health Campus mental health unit in July 2010.
The coroner will examine the cause and effect of Mr Church’s illness, whether it was appropriate to transfer him to an open ward, and what precautions were taken to remove potentially dangerous items from the open ward given that he was at high risk of suicide.
In her opening address on Monday, counsel assisting the coroner Ilona Burra-Robinson said Mr Church suffered from severe migraines and was in almost constant pain.
He was intermittently referred to psychiatric care and was prescribed various medications, including antidepressants, but would often self-medicate for pain, she said.
Mr Church’s daughter Karen Frances Sibbrett testified her father took medication every day and would “mix and match and alter the doses”, so she recommended he keep a book to record what he was taking.
She said her father did not believe he was depressed – but that he had a pathology issue with his brain – although he did talk about suicide with anyone who would listen.
He had pre-paid his funeral, Ms Sibbrett said.
“He was ready to exit and he’d talk that way for a very long time.”
Ms Sibbrett said her father was experiencing hallucinations and acting more aggressively towards the end of his life.
“I think he was losing his grip on reality a little bit,” she said.
Ms Sibbrett was critical of the level of care her father received and said there had been a “string of poor duty of care” that led to his suicide.
“I felt that I wasn’t being listened to,” she said.
The inquest continues.
* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14.