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A heartbroken widower from Faversham was knocked down and killed by a lorry after fleeing a hospital to visit his wife's grave, an inquest heard.
Alfred Cole, 82, escaped from a secure dementia ward and was walking to the final resting place of his beloved Irene when he was hit by the truck.
The retired labourer had been admitted to Ashford's William Harvey hospital after he kept running away from the Mill House care home.
On one daring dash from the Salters Lane home, he scaled a 6ft wall and was later found 200 miles away in Cardiff.
But four days after arriving at the hospital last summer, he slipped away unnoticed from the ward - described by the coroner as "unavoidably short-staffed" - and was hit by a lorry in the early hours of July 25.
An inquest into his death heard he was knocked down on the A249 near Bobbing crematorium, where his wife of 58 years was cremated after her death in 2008.
Mr Cole's daughter Carol Akhurst told the hearing he had "never fully recovered" from losing Irene, who he affectionately called "his Reenie".
She added he had developed dementia in the years following her death, contributing to his continued attempts to flee the care home.
She said: "All these things were put in place to safeguard him, but he saw it as if he was being imprisoned. He just wanted his freedom and to be with my mum."
Consultant psychiatrist Dr Deborah Connolly told the inquest how, in an assessment at Mill House, Mr Cole had spoken of his wish to "die and be with his wife", raising fears he had been at risk of self-harming.
"He would ring up and say he wanted to throw himself in front of a bus..." - daughter Carol Akhurst
But coroner Alan Blunsdon ruled Alfred's death was an accident – a verdict Carol was happy with.
She said: "It knocked the life out of my dad when mum died and he never fully recovered from it.
"He would ring up and say he wanted to throw himself in front of a bus, but even though he was part serious, I knew he wouldn't do it. He promised me a number of times that he wouldn't do that to me.
"He wasn't a particularly religious man, but he appreciated Christian values and would say to me 'I wouldn't do that to you Carol because suicide is a sin and then I'd go to hell and I wouldn't go to my Reenie'.
"He was lost without my mum. What will be, will be, and it's done now – he's with my mum, his wife, his Reenie."
In a fatal mistake, not one of the nurses on duty during Mr Coles's time in the hospital had checked his notes, which said he was at risk of fleeing, the inquest heard.
The coroner ruled a combination of lack of staff, communication and other patients needing help had led to a moment of blindness where Mr Cole was able to slip away.
"There was no indication that he was at risk of absconding..." - ward manager Simon Lockwood
The inquest heard Dr Connolly had diagnosed Mr Cole's with agitated depression and dementia and suggested he should be urgently admitted to Winslow Ward on the Arundel Unit at the Ashford hospital - a specialist unit for elderly people suffering dementia.
During Mr Cole's four days in the ward, nurses described him as "calm and pleasant".
But duty nurses and ward manager Simon Lockwood admitted during the inquest that not one of them had read Dr Connolly's letter outlining Mr Cole's risk of escaping and self harm.
Despite him trying to open code-locked doors with a butter knife, staff in the ward said they did not see Alfred as a risk.
Mr Lockwood said: "There was no indication that he was at risk of absconding."
The coroner said: "Management should have been better, with better communication, but we know that the ward was unavoidably short-staffed.
"But no higher level of observation would have stopped him in the end. As his daughter has said, Alfred was a determined man.
"They were fighting a losing battle with Alfred and he wanted to leave and would eventually find a way."
The Winslow Ward was investigated after Alfred's death in July 2012. A report criticised the ward and its management. The ward closed in January this year.
Mr Cole's body was found at just before 3am on July 25 last year on the Bobbing slip road of the A249 near Sittingbourne.
His walking stick and watch were found next to him and a post-mortem examination found the cause of his death was multiple injuries.
The lorry, driven by Robert Saunders, had been travelling from a Morrisons depot in Kemsley to Gibraltar.
The vehicle did not stop at the scene, but was later pulled over in Bordeaux, France where it was assessed.
The driver and passenger both failed to realise the lorry had hit Mr Cole, thinking they had struck something else.
Robert Giles, a forensic collision investigator, said: "Both were aware that the car had hit something.
"Neither of them saw a pedestrian and the 'clunk' they heard was most probably the car hitting the walking stick."
