AN elderly resident was able to escape from an Adelaide nursing home before dying in "horrendous" circumstances, an inquest has found.

State Coroner Mark Johns today was scathing of security measures in place at Saint Hilarion Aged Care on Henley Beach Rd at Lockleys when Rolando Cecere died in January 2006.

Mr Cecere, 71, was suffering dementia and schizophrenia and had made numerous attempts at escaping the aged care facility leading up to his death.

His body was found hanging from a fence at the nursing home in the early hours of January 26 and an autopsy found he died of "positional asphyxiation."

The Coroner said Mr Cecere should not have been able to find his way out of the home if proper security had been in place.

"The premises were not capable of safely containing a person such as Mr Cecere who actively tested the boundaries of his environment in order to find a means of escape. It was a matter of time before he succeeded," Mr Johns found.

Mr Johns said it was "reprehensible" that Mr Cecere met his death in the manner he did.

"Had Saint Hilarion been properly secured, this would not have happened. Mr Cecere's death in such distressing circumstances was entirely avoidable," he said.

Mr Johns said the circumstances surrounding the death were "horrendous."

He recommended that the Commonwealth Department of Health and Ageing and the Aged Care Standards and Accreditation Agency conduct a "thorough review" of the facilities, practices and policies of the centre.

The Coroner said the inquiry should examine whether Saint Hilarion is properly equipped to house dementia patients and whether staffing levels were sufficient to provide appropriate care.

Mr Johns commended security changes made by the home's management since Mr Cecere's death, including the installation of coded security keypads and increased monitoring of residents.

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Source: The Advertiser - Andrew Dowdell, Court Reporter