A young Tasmanian mother's suicide was entirely avoidable, a coroner has warned in the wake of her death.
The woman, identified only as CL, killed herself in May 2019. Days earlier she had been at a hospital in the state's north-west after a suicide attempt at home.
Coroner Robert Webster said staff at North West Regional Hospital in Burnie made a substandard assessment of CL's suicide risk after the previous attempt.
The coroner's report made a series of recommendations, including better assessment training for psychiatric staff and more thorough completion and recording of assessments by mental health care staff.
CL, 33, was a mother of two and had separated from her children's father years earlier.
She battled with alcohol abuse, her mental health and a childhood history of abuse.
Staff failed to take into account CL's recorded history of suicide attempts, alcohol abuse and mental health history, the coroner said.
The report also found CL had been improperly discharged from hospital. Staff had recorded her being discharged directly in the care of a friend, but the same friend told Mr Webster she picked up CL from outside the hospital.
Days later CL was found dead by her mother and a friend at her home after failing to show up to work or answer her phone.
The head of Tasmania's Mental Health Services defended the actions of staff, saying the state's mental health laws had to respect the autonomy of patients.
CL had denied historical suicide attempts and ideation to mental health staff.
But Mr Webster said if CL's history had been properly assessed and procedures followed, she would have been subject to voluntary admission - where the patient can choose to stay for their own safety and care at a mental health facility.
Instead staff chose to discharge her.
"CL's death was entirely avoidable," Mr Webster said.
"It occurred because of a substandard assessment of her suicide risk which led to the decision to discharge her rather than admit her for treatment."
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