SA coroner lashes mental health system

The South Australian coroner has lashed the state's mental health system after it failed two men who took their own lives, soon after being released from hospital.

Coroner Mark Johns says it's unacceptable the two men were not seen by a trained psychiatrist after being detained by police under the Mental Health Act.

"Once again we have a case in which there has been a significant failure by this state's mental health system," Mr Johns said in his findings into the two deaths on Thursday.

"If that is the best the state's mental health system can do, it is difficult to find words sufficient to match the severity of the problem."

Mr Johns investigated the deaths of Robert Campbell, 53, and Jeremy Todd Williams, 24.

They took their own lives soon after being released from hospital where they had been taken by police amid concerns for their safety.

The coroner said the actions of Mr Campbell in particular were so serious that it was "simply beyond comprehension" that they didn't warrant the attention of a psychiatric consultant or, at the very least, a psychiatric trainee.

He said that should be "condemned in the strongest possible terms".

"The system almost seems designed to produce a lack of continuity of care," Mr Johns said.

"I firmly believe that mental health patients need to have someone in whom they can place their trust and in who they can feel is prepared to take control of their situation, assist them and care about them.

"And yet, the disjointed mental health system operating in this state would almost appear to be designed to achieve anything but that outcome."

Among his recommendations the coroner has called for increased training for people treating mental health patients and also that no one at risk of suicide and detained under the Mental Health Act be discharged from hospital without input from a psychiatric consultant or registrar.

* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14, Suicide Call Back Service 1300 659 467, MensLine Australia 1300 78 99 78.