A 70-year-old man drowned at Changi Beach Park after he absconded from a welfare home, but the police were not immediately informed that he had gone missing.
The death, on Nov 9 last year, of Mr Poh Hwe Chee, a resident of the Tembusu Home in Pelangi Village in Buangkok Green, prompted the authorities to tighten procedures when welfare home residents go missing or unaccounted for.
The home's superintendent has since directed staff to report to the police immediately any case of a resident who goes missing.
Since March, the Ministry of Social and Family Development (MSF) has also reviewed and developed a new set of guidelines under the "failure to return to welfare home" provision.
A police report has to be lodged within 24 hours once the resident has escaped from legal custody, or if the superintendent assesses the resident's safety to be at risk or if he poses a risk to others.
A coroner's inquiry, which was held on April 20 and last Friday, heard that police were not immediately told of Mr Poh's abscondment from the home until after his death.
His drowning was yesterday found to be a case of suicide.
State Coroner Marvin Bay said in his findings: "This is certainly a step in the right direction.
"The guidelines now accord an appropriate level of urgency to any abscondment, and prioritise attention and action where there is any apprehension of risk to the safety of the inmate, or to other persons."
People who are placed in homes often have physical, mental and intellectual vulnerabilities, and may be at risk of self-harm or injury, particularly when they find themselves unsupervised, left to their own devices, outside the safety of a home, he said.
"Given the above, it is imperative that police help be expeditiously sought where a home resident goes missing," said Coroner Bay.
Previously, a report could be lodged only after a person had been absent for more than 24 hours.
A fully clothed Mr Poh, who had been living at the home since Dec 5, 2014, was found lying face down about 3m away from the shoreline at Changi Beach Park at about 11pm on Nov 9 last year.
His pair of slippers and wallet were found 10m away.
The court heard that he had been treated in hospital after an altercation with another resident on Nov 2.
Six days later, he was accompanied by a nursing officer to a medical review at Hougang Polyclinic when he disappeared after telling the officer to collect the medication on his behalf.
The Tembusu Home superintendent reported Mr Poh's disappearance to Ang Mo Kio police on Nov 9 by letter. This complied with previous MSF guidelines.
Coroner Bay also said in his findings that Mr Poh had a "severely strained" relationship with his family members. He had been left to fend for himself after his step-daughter sold his Jurong West flat in late 2014.
This unfortunate history, Coroner Bay said, had left Mr Poh depressed and bitter. He kept to himself and rarely interacted with anyone at the welfare home. He had tried to kill himself by burning newspapers and cutting his wrists before he was admitted to the home.
Coroner Bay said the evidence pointed to Mr Poh contriving to abscond when he was left on his own at the polyclinic.
"By the time he had gone to Changi Beach, it is likely that he had developed a suicidal intent, possibly because his attempts to locate his step-daughter had been thwarted," he said.
