5 days ago
Dehydration determined as cause of death for dementia patient missing from Qld hospital
Not a day goes by that Rod Roach does not think about his older brother Peter who walked out of a Queensland hospital never to be seen again.
Peter Roach was a patient on an unsecured ward at the Rockhampton Hospital in central Queensland when he walked out while staff were responding to a nearby emergency in May 2023.
The 80-year-old — who was deaf, non-verbal, and suffered from dementia — was not reported missing for at least two hours.
Despite a days-long extensive land, air and water search, Peter was never found.
"[It's] unbelievable. They knew that he was a bit of a wanderer, and he was still able to get out," Mr Roach said.
After Peter's disappearance, another two elderly patients — both with Alzheimer's disease — walked out of central Queensland hospitals.
Not being able to properly farewell his brother has left Mr Roach feeling empty and searching for answers.
"There's no closure, not at all," he said.
Australia's peak body for dementia advocacy said it was a national issue that families were increasingly raising.
With an aging population it is a complex, multi-pronged problem that has prompted calls for change.
A report from the Central Region's Coroner's Court of Queensland, issued in May this year, said Peter was last seen walking along Bowlin Bridge Road in east Rockhampton around 5:15pm on the day he went missing.
Coroner David O'Connell confirmed he died from dehydration, likely due to exposure to the environment.
"[It's] very likely he would have succumbed within a short period of time after he was last seen alive," the report read.
It was not the first time Peter had wandered from hospital.
Right to Information documents, obtained by the ABC, showed during his 55-day stay Peter had left the hospital multiple times and was known to sit by the exit on the ward.
Action Review Meeting (ARM) and Human Error and Patient Safety (HEAPS) reports in the months after he disappeared included detailed reviews of the incident.
Subsequent changes were put in place on all wards at Rockhampton Hospital with patients at risk of wandering, including:
Central Queensland Health and Hospital Service (CQHHS) chief executive Lisa Blackler said the "deepest condolences" went out to Peter's family.
"[It] deeply impacts not only his family but us as a healthcare provider, and we're doing everything we can to support great care to central Queenslanders and leaning in where we can for these types of patients," Ms Blacker said.
She conceded striking a balance between keeping patients safe, while also respecting their freedoms, was a challenge.
While the CQHHS said it had learnt lessons from Peter's disappearance, he would not be the last cognitively-impaired patient to walk out of a central Queensland public health facility.
About 14 months after Peter left the Rockhampton Hospital, for what would be the last time, 80-year-old Margaret Carvell went missing from the same facility's emergency department.
She was found hours later, in the evening, about 3 kilometres away.
On a morning in March 2025 patient Edward Camille, 65, wandered from a surgical ward in the Gladstone Hospital, a facility about 100km south of Rockhampton that is also run by the CQHHS.
He was also found several hours later.
Ms Blackler said these two cases were different circumstances to Peter as they were not long-stay patients.
According to the most up-to-date data from the Australian Institute of Health and Welfare hospitalisations due to dementia rose to 26,300 in the 2022-23 financial year.
It does not have data on the instances of those patients wandering from hospital.
Dementia Australia said part of the problem was a shortage of beds in aged care facilities gridlocking hospitals.
Executive director Kaele Stokes said hospitals were not designed for patients with a cognitive impairment to stay long-term.
"What we hear increasingly is that for people who are living with a cognitive impairment … it's often not a very supportive environment for them," Ms Stokes said.
"It can add to their symptoms of cognitive impairment … [by] not feeling secure and choosing to leave that environment, which then adds additional stress for both the family and hospital staff.
"That can [also] result in adverse medical outcomes and people needing to stay in hospital longer."
But for some, like Peter , staying in hospital until an aged care bed becomes available was a necessity as it was not safe to return home.
Queensland Health data from May this year showed there were more than 800 public hospital elderly long-stay patients across the state, of which 630 were awaiting a place in residential aged care.
That was up from 539 in May 2023 when Peter went missing.
Aged and Disability Advocacy Australia [ADA] said it also found it was more difficult for people with chronic health conditions or high support needs to access aged care.
ADA chief executive Geoff Rowe said more investment was needed, not just in residential care but also at-home care.
He said recent reform in the sector, prompted by the royal commission, was welcome but did not go far enough.
Federal Minister for Aged Care and Seniors Sam Rae said the government was spending almost $1 billion on helping providers build, maintain and expand aged care homes.
But in some communities services are taking matters into their own hands.
In November last year CQHHS teamed up with an aged-care provider to roll out 30 extra interim-care beds in Emu Park on the Capricorn Coast for elderly hospital patients waiting for aged care beds.
As for reducing the risk of patients wandering, Dementia Australia stressed the need for quiet patient spaces and more staff training.
"Introducing yourself when you walk into a room, explaining why you were there, explaining why the person living with dementia is there, and what you're there to do can make a difference to helping to orient that person," Ms Stokes said.
She said even simple observations of a patient's food and drink consumption could prevent flow-on medical effects.
"Often we hear that someone with a form of dementia might not know to pull the top off the cup … so they don't drink anything and somebody comes in and takes the tray away," Ms Stokes said.
CQHHS's Ms Blackler said staff did their best to ensure basic daily living schedules were adhered to but it was not always possible, "particularly in the shared room or a very busy patient ward".
Both Dementia Australia and CQHHS also stressed the importance of family being involved in medical care plans and raising concerns.
In addressing Rod Roach's concerns that information was not forthcoming from the hospital after his brother's disappearance, Ms Blackler apologised and said that the service always strove for transparency.
For Mr Roach, the changes in hospital protocol have come too late, but he hopes no other family will have to go through what he has endured.
"I just hope they will change their attitude towards dementia patients," he said.
"I don't want any anyone to go through a loved one walking out of a hospital and never be seen again. It's not a good feeling."
