The family of Sandra d'Auriol, the Hong Kong jewellery designer and philanthropist who fell to her death after having cosmetic surgery in Los Angeles, wants better training for staff so they can spot vulnerable patients and prevent similar tragedies.
D'Auriol had just undergone 13 hours of surgery on January 22 when she suffered what was believed to be a "neuro-behavioural disturbance" and jumped off the roof of the Beverly Hills clinic.
"The mind boggles that Sandra was able to overpower a nurse, outrun a security guard and find her way two floors up to the roof in an office building which we've been told has no high fencing. We are appalled," said her brother-in-law Guy d'Auriol, speaking publicly for the first time since the tragedy on behalf of the family.
He said patient safety should be improved.
"However, this is not a matter for us, this is a matter for the police to investigate," d'Auriol said. "While we realise nothing is going to bring back Sandra, we feel her tragedy will help raise awareness, that it could possibly save others."
A clinical review published in the British Medical Journal in 2011 said "neuro-behavioural disturbances are common complications" of operations.
The most serious - post-operative delirium - can last for weeks in some cases, resulting in aggressive behaviour, hallucinations and delusions.
A naked Sandra d'Auriol, 53, spent more than three hours on the ledge of the roof, occasionally humming and singing.
Police psychologists made repeated attempts to engage with the mother-of-three.
D'Auriol lost a son, aged 12, in a swimming accident in Bali in 2004.
"It was so out of character for Sandra … the violent behaviour," her brother-in-law, a Hong Kong-based investor, said.
"It is so shocking; we cannot reconcile this with the Sandra we knew.
"The symptoms are very clear, everybody can list the symptoms - but the causes are totally a mystery - and this is how you progress in science."
In the long term, the d'Auriol family want to see more medical research into the side effects and impact of anaesthetics.
"We can only hope this leads to better, less-risky drugs," d'Auriol said. Asked whether this was a tragedy that could have been prevented, he said: "This is something that will become clear when the police report is released.
"In the short term, what we can focus on is better disclosure to the patients of the risk - so that we can make that informed decision."
Born in India to British parents, d'Auriol moved to Hong Kong in 1983 and had been associated with the Child Welfare Scheme since 1999, a charity she co-founded.
Her jewellery, with a focus on jade, was exhibited in London, Paris, New York and Milan, with all the profits donated to the more than 30 children's, women's and environmental charities she supported.
Talking of d'Auriol's decades-long, multimillion-dollar charitable contributions, Guy said: "I think it was immense. Sandra was more than a fundraiser - she was a creative force in her charitable contributions.
"Her force of persuasion was immense, and we were all willing victims of her good deeds."
Last Thursday, a spokesman for the Beverley Hills Police Department, Lieutenant Lincoln Hoshino, confirmed that it was investigating the death.