Junior doctors should not be able to independently discharge suicidal patients, says a coroner who investigated the death of a man who lost his family in a bushfire five years earlier.

Damian Kay, 38, jumped to his death from an Adelaide hotel on September 22, 2010, two days after police took him to Lyell McEwin Hospital following concerns about a three-page suicide note he had written.

But the hospital’s first-year resident medical officer, Dr Thi Nguyen, discharged Mr Kay, telling the inquest he was 100% convinced that Mr Kay would not self-harm, as Mr Kay had told him this.

In findings handed down on Wednesday, SA State Coroner Mark Johns listed nine omissions made by Dr Nguyen including his failure to ask for, and then read, the suicide note.

Mr Kay’s wife and two children were killed when her car hit a tree as she tried to flee the Eyre Peninsula bushfires in January 2005.

Mr Kay was later treated by psychiatrists. He formed a new relationship but when it broke down, he wrote his ex-partner the suicide letter.

The coroner said Dr Nguyen failed to attribute any significance to the fact that Mr Kay reported “recently” stopping antidepressants or to the later revelation that he made a previous suicide attempt.

Mr Johns heard evidence from mental health expert Dr Andrew Champion, who said the suicide note “demonstrated a high level of implicit intent regardless of Mr Kay’s subsequent statements”.

“It was Dr Champion’s view that in Mr Kay’s case there was evidence of significant suicidal risk and that Dr Champion considered that there were grounds to make a detention and treatment order,” the coroner said.

The coroner said he was particularly struck by the doctor’s comment that people presenting with suicidal ideation have always been part of the core business of EDs.

His recommendations to the SA Minister for Mental Health and Substance Abuse included that a junior doctor or mental health nurse should not discharge a suicidal patient from an ED without seeking advice from a senior medical colleague.

Before discharging such a patient, a minimum set of information should be obtained and there should be “assertive follow-up” of suicidal patients.

Further, the health department should ensure that training in the assessment of suicidal risk should be provided to medical undergraduates and doctors working in EDs.

As first appeared in Psychiatry Update, 6 September 2012