SINGAPORE - A 70-year-old man drowned at the Changi Beach Park after he absconded from a welfare home where he was staying, but the police was not immediately informed that he had gone missing.
The death of Poh Hwe Chee - a resident at the Tembusu Home at Pelangi Village at Buangkok Green - on Nov 9 last year has prompted the authorities to tighten procedures when welfare home residents go missing or unaccounted for.
The home's superintendent has since directed that staff must report to the police immediately any cases of residents going missing.
Since March this year, 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 is at risk, or poses a risk to others.
A coroner's inquiry, which was held on April 20 and last Friday, had heard that police were not immediately told of Poh's abscondment from the home until after his death. His drowning was found on Monday (May 8) 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 prioritises attention and action where there is any apprehension of risk to the safety of the inmate, or to other persons.''
Persons 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,'' he said.
Previously, a report could only be lodged after a person had been absent for more than 24 hours.
Poh, who had been staying at the home since Dec 5, 2014, was fully-clothed and lying face down about 3m away from the shore line at Changi Beach Park at about 11pm on Nov 9 last year. His pair of slippers and his wallet were found 10m away.
The court had heard that he was treated in hospital after an altercation with a resident on Nov 2.
Six days later, he was accompanied by a Home nursing officer for a medical review at Hougang Polyclinic when he asked the latter to collect his medication on his behalf. He had complained that his back was in pain.
About 10 minutes later, he was missing. The Tembusu Home superintendent reported to Ang Mo Kio Police about Poh's disappearance on Nov 9 by letter. This complied with the previous MSF guidelines.
Coroner Bay also said in his findings that Poh had a "severely strained'' relationship with his family members. He had been left alone in Singapore after his step-daughter sold his Jurong West flat in late 2014.
This unfortunate history, he said, had left Poh depressed and bitter. He kept to himself and rarely interacted with anyone at the 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 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 before finding that Poh's drowning was a "deliberate act of suicide''.