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Coroner blasts SA govt over death of man

AAP logoAAP 17/11/2016 Rick Goodman

A coroner says the South Australian government must bear responsibility for the "lamentable state of affairs" that led to a 22-year-old man taking his own life.

Queensland tourist Ross Matthew Alcock died in February at the Royal Adelaide Hospital after he hanged himself inside the wardrobe of his room on the mental health ward.

SA Coroner Mark Johns said the blame ultimately fell to the state's mental health system.

He ruled that Mr Alcock's death could have been prevented, lashing the state's mental health system for the circumstances that enabled it.

"It is, to say the least, unacceptable that Mr Alcock had the means and opportunity to take his own life while admitted as a detained patient in a tertiary hospital such as the Royal Adelaide Hospital on a ward dedicated to mental health patients," Mr Johns said on Thursday.

He said the equipment in Mr Alcock's hospital room and the layout of the ward contributed to the death.

The room contained two beds separated by a wardrobe running between them, with only the foot of the rear bed visible from the doorway.

The coroner also found the nurse responsible for Mr Alcock's half-hourly checks did not understand his role properly and did not complete all the required checks.

"He was incorrectly under the assumption that all of the staff were responsible for the round checks and did not appreciate that it was his individual responsibility," Mr Johns said.

But he said it was "unfair to single out individual employees who must work within this mental health system".

"It is the government of the state that must bear responsibility for the lamentable state of affairs which enabled Mr Alcock to take his own life."

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.

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