The South Australian coroner is recommending the number of beds dedicated to mental health care in this state be radically increased, after examining the death of a young woman at Mt Barker hospital in 2015.
Twenty four year old Chrystal Ross took her own life at the hospital after she was told she would be released instead of being transferred to the mental health facility at Glenside.
The coroner heard how a bed had become available for Chrystal but due to errors by the Community Mental Health Team, it was cancelled, a move Coroner Mark Johns says is a symptom of a system that doesn’t have enough resources.
The court also heard that a psychiatric nurse working at the hospital had wrongly assumed that Chrystal had Borderline Personality Disorder and was bent on discharging her, another nurse tesitfying that she heard him say "these types of Borderline Personality Disorder girls need to start taking responsibility for their own actions" and "the longer these types are in the worse they get".
Mr Johns believes that if the nurse hadn't intervened that day and told Chrystal that she was to be sent home, she would most likely still be here.