Lynette Roberts, aged 49, died at 9.15pm on December 16, 2010, when she was struck by a car in Dunolly after travelling to the town from Bendigo earlier in the day.

She was living in the community care unit at Vahland House at the time, which allowed psychiatric patients to leave the facility during the day.

On December 13 she was transferred to the community care unit from the secure extended care unit, which restricts patient movement, after it was decided she was responding well to anti-psychotic medication.

On both December 14 and 15 – the two days prior to her death – Ms Roberts had told staff she was going to Long Gully IGA but had instead walked to visit relatives on Napier Street. Her relatives were told Ms Roberts would no longer be allowed out of the facility, but that order did not eventuate.

When her whereabouts became unknown on December 16, it was resolved to transfer her back to the secure unit.

Nurses noted she had not returned from her outing at 1.30pm, but a search did not start until 5.10pm.

Ms Roberts had managed to hitchhike to Dunolly from near Maldon where she obtained cigarettes and alcohol. She was struck by a car before police could locate her.

Coroner Jennifer Tregent recommended that Bendigo Health create a “clear policy” for when community care patients leave the grounds of the psychiatric facility, and that next of kin be notified 24 hours before a patient is moved from the secure unit.

She also recommended that staff be given regular training in risk assessments and be required to make comprehensive patient notes at the end of their shifts.

Ms Tregent said nurses “were genuinely concerned for her best interests” and were not at fault.

She said the search for Ms Roberts was unnecessarily delayed.

“I do not agree that Lynette could not be said to have been engaging in high risk behaviour,” Ms Tregent said.

“As was known to (the nurse), Lynette had the ability to travel long distances and procure alcohol even without the benefit of financial assistance.

“Given these facts were known to (the nurse) and other nursing staff in the morning and afternoon shifts, the search for Lynette should have commenced earlier.”

A spokesperson for Bendigo Health said the health service would respond once relevant staff had analysed the findings.