The family of Malcolm ''Mac'' West is still looking for answers after the suicide death of their beloved husband and father while in the care of a psychiatric treatment facility.
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But Coroner Maria Doogan ruled yesterday Calvary Hospital's private mental health facility, Hyson Green, was not to blame for Mr West's death in June 2009.
She was satisfied it was professionally run and staffed by appropriately qualified, trained and experienced health professionals.
''Members of the public might assume that a mentally ill person prone to suicide will be kept alive by their placement in a specialist mental health treatment facility,'' she wrote.
''Regrettably this is not always the case. Short of 24-hours a day, seven days a week personal one-on-one supervision, a person determined to take his or her life will find a way to do so.''
But the dead man's wife Sally Richards and sons Tim and Duncan are frustrated and angry at the findings.
''That just seems completely incomprehensible to me,'' Ms Richards said.
''Something went badly wrong - a man is dead.''
The trio yesterday described Mr West as an ''enormously talented man'' full of life.
Duncan West recalled friends being ''absolutely stunned that this vivacious, charming and witty individual who was the life of all the parties had this deep-seated depression''.
The 57-year-old's death left Ms Richards caring for their profoundly disabled son Jackson.
''So while the [legal] procedures are over, Mum lives with this forever,'' Tim West said.
Mr West was diagnosed with depression in 1980 and was later found to have bipolar disorder.
The father of four had been hospitalised five times and tried to take his own life during a previous visit to Hyson Green 18 years earlier.
Mr West was again admitted to Hyson Green in early May 2009, and was returned home several weeks later.
He was readmitted again on May 30 after expressing suicidal thoughts and classified as a medium/low-risk patient to be checked on every hour and not permitted to leave.
On the morning of June 1, he was reclassified as low risk, at his request, so he could go for walks in the surrounding bushland.
The reduced category meant Mr West only had to be checked on every six hours; the family argues this window gave him the opportunity to take his own life.
He was found dead in his room on June 2 when a nurse came to tell him Tim had phoned.
Ms Richards and her sons believe the decision to lower Mr West's risk category was a fatal mistake given his history.
But the coroner said there was no evidence Mr West divulged a plan to kill himself, rather that he was talking to staff and going for walks in the bush.
She was not persuaded the decision to reclassify him was inappropriate.
The family also raised concerns Mr West had been put on a new medication in the lead-up to his death - one which may have increased the risk of suicide.
But Ms Doogan said in light of the evidence of experienced psychiatrists, ''I cannot make a finding that Mr West's suicidal ideation was exacerbated by the drug.''
The coroner expressed her sorrow for the family's loss.
Calvary Health Services chief executive Ray Dennis said the hospital had reviewed and overhauled its classification procedures in the aftermath of the incident.
''It's important that we do acknowledge and appreciate that it is a very difficult time for Mr West's family,'' Mr Dennis said.