'Missed opportunities' for urgent psychiatric assessment of teen, coroner findsBy Jordanna SchrieverTopic:Courts16m ago16 minutes agoThu 8 May 2025 at 8:16pmThe Deputy State Coroner handed down his findings this week. (ABC News: Lincoln Rothall)In short:A coroner has handed down findings into the death of a teenager experiencing mental ill-health who took his own life three days after being released from a high dependency unit in an Adelaide prison.The coroner said it "would have been best" to have the 18-year-old's psychotic state treated and controlled before releasing him on bail.What's next?The state government says it will give "serious consideration" to the recommendations in the coroner's report.abc.net.au/news/coroners-findings-into-death-of-teen-days-after-being-bailed/105267460Link copiedShareShare articleA First Nations teenager experiencing mental ill-health who took his own life after being released on home detention bail "would have been better placed had he not received bail" and remained in prison, a coroner has found.The teen died on September 14, 2019, just three days after being released from the high dependency unit (HDU) in Yatala Labour Prison, in Adelaide's north, on September 11, 2019.If you or anyone you know needs help:Suicide Call Back Service on 1300 659 467Lifeline on 13 11 14Aboriginal & Torres Strait Islander crisis support line 13YARN on 13 92 76Kids Helpline on 1800 551 800Beyond Blue on 1300 224 636Headspace on 1800 650 890ReachOut at au.reachout.comMensLine Australia on 1300 789 978QLife 1800 184 527In findings handed down this week, South Australian Deputy State Coroner Ian White said that while in prison on charges of affray and property damage, the 18-year-old was "physically safe from taking his own life"."It pains me to say that, from what we know now and his observed behaviours and words, [the teen] would have been better placed had he not received bail and remained at Yatala in HDU at that time in September 2019," he said."This goes against every principle concerning the detriment to Aboriginal people of being in custody awaiting their outcome of criminal charges against them."It would have been best for him to have his psychotic state treated and controlled before releasing him on bail."The teenager was released from the high dependency unit within Yatala Labour Prison in 2019. (ABC News: Che Chorley )He said the teen was a "very troubled and disadvantaged young Aboriginal man".The findings note the teen was granted release on electronically-monitored bail during a hearing at Elizabeth Magistrates Court, but that the court was not told of his "struggles" while in custody.Mr White said prison health staff had identified the teen as "clearly experiencing psychotic symptoms" requiring constant supervision, placing him in the HDU."Inadvertently, [the teen] was released without any referral to see a psychiatrist," Mr White said.The day after his release to live with his sister, the teen attended a Department for Correctional Services office and "almost immediately" began making "concerning statements including about harming others and being possessed by the devil".A compliance officer made a referral to the Acute Crisis Intervention Service, who advised the compliance officer to call SAPOL and request a welfare check.SAPOL did not conduct a welfare check, the coroner found. (ABC News: Che Chorley)But, Mr White said SAPOL "did not honour the request"."SAPOL never conducted this welfare check, thus losing the chance to change the course of events by making a potential assessment and ensuring follow-up care," he said.Meanwhile another referral was made to the Northern Community Mental Health Service about 5pm on September 12, 2019, but not allocated until midday the next day, Friday, September 13.The allocated staff member attempted to visit the teen, but had an old address and discovered his new residence fell outside the team's catchment area.According to the findings, the staff member had resolved to find the correct address the following Monday, because a response had been triaged as "non-urgent" despite the teen having symptoms which "would ordinarily necessitate a rapid response".The teenager was released from Yatala without any referral to see a psychiatrist, the coroner found. (ABC News: Che Chorley)The findings note two other DCS staff members visited the teen on the Friday, and noted his "quiet and withdrawn" demeanour and that he was "suffering from some kind of mental health condition" but said the teen repeatedly assured them "everything was fine".Mr White said an expert consultant psychiatrist who gave evidence at the inquest had identified "missed opportunities to obtain urgent psychiatric assessment and treatment" for the teen."It is true that any variation of the events and responses could have caused a vastly different outcome," Mr White said.He made three recommendations around improved information sharing between the state's youth and adult prisons and between public health clinicians and prison health, and to permanently implement improvements made since the teen's death.Chris Picton says the government will give "serious consideration" to the recommendations. (ABC News)In a statement, Health Minister Chris Picton extended his sympathies to the teen's family."The state government will give serious consideration to the recommendations in the Deputy State Coroner's report," he said.A Department for Correctional Services spokesperson similarly said any death like the teen's was "sad and tragic"."The department has received the coroner's report and will give his recommendations active consideration," the spokesperson said.South Australian Police (SAPOL) also said it was considering the findings and will "make further assessment regarding the relevance of the findings to SAPOL's current policies and practices"."As the incident took place around six years ago, some findings made during the Inquest were regarding SAPOL practices that have since been changed," SAPOL said in a statement.Posted 16m ago16 minutes agoThu 8 May 2025 at 8:16pmShare optionsCopy linkFacebookX (formerly Twitter)If you need someone to talk to, call:Lifeline on 13 11 14Kids Helpline on 1800 551 800MensLine Australia on 1300 789 978Suicide Call Back Service on 1300 659 467Beyond Blue on 1300 22 46 36Headspace on 1800 650 890QLife on 1800 184 527Top StoriesAmerican Robert Prevost elected pope and will be known as Pope Leo XIVLIVEPhoto shows A man in religious robes looks down from a balconyPrice defection slammed as hostile 'Joh-for-Canberra' Liberal takeoverTopic:Political LeadershipPhoto shows Federal shadow minister for Indigenous Australians Jacinta Price standing and speaking outside a voting centre.Drained batteries and broken trust: Energy giant denounced over clean tech schemeTopic:Energy IndustryPhoto shows Man wearing baseball cap and khaki green t-shirt standing next to household Tesla batteryUS and UK strike deal as Trump slashes tariffs on British steel, carsTopic:TariffsPhoto shows Keir Starmer and Donald Trump shake hands and make eye contact Meeting with hate preacher triggers court order for notorious terror leaderTopic:ExtremismPhoto shows image of convicted terrorist Abdul BenbrikaPopular nowAmerican Robert Francis Prevost elected pope and will be known as Pope Leo XIVLIVEPhoto shows A man holds a sign in Italian which translates to 'up with the pope' at the Vatican in a huge crowdPrice defection slammed as hostile 'Joh-for-Canberra' Liberal takeoverTopic:Political LeadershipPhoto shows Federal shadow minister for Indigenous Australians Jacinta Price standing and speaking outside a voting centre.Drained batteries and broken trust: Energy giant denounced over clean tech schemeTopic:Energy IndustryPhoto shows Man wearing baseball cap and khaki green t-shirt standing next to household Tesla batteryRelated topicsAdelaideCourtsMental HealthNorthfieldSASuicideTop StoriesAmerican Robert Prevost elected pope and will be known as Pope Leo XIVTopic:Religious LeadersPhoto shows A man in religious robes looks down from a balconyPrice defection slammed as hostile 'Joh-for-Canberra' Liberal takeoverTopic:Political LeadershipDrained batteries and broken trust: Energy giant denounced over clean tech schemeTopic:Energy IndustryUS and UK strike deal as Trump slashes tariffs on British steel, carsTopic:TariffsMeeting with hate preacher triggers court order for notorious terror leaderTopic:ExtremismJust InTeen should have had 'psychotic state treated' before being bailed, coroner findsTopic:Courts16m ago16 minutes agoThu 8 May 2025 at 8:16pmAward-winning parenting program tackling disadvantage loses fundingTopic:Regional Communities19m ago19 minutes agoThu 8 May 2025 at 8:13pmCalls for vehicle checks as invasive ants found near K'gariTopic:Pests40m ago40 minutes agoThu 8 May 2025 at 7:52pmCommunity effort to send Tassie girls to Florida ends with goldTopic:Feel Good25m ago25 minutes agoThu 8 May 2025 at 8:07pmMore Just InBack to top