A psychiatrist who sent a potentially suicidal young man home from hospital has been found to have breached a medical rights code because he did not adequately assess the risk.
The young man subsequently died in an incident later that day.
Mental Health Commissioner Kevin Allan's report found the psychiatrist did not provide reasonable care to the man and that he did not take into account the concerns of the man's parents .
The psychiatrist made two assessments of the man after he initially visited a hospital emergency department with his parents complaining of testicular pain.
When hospital staff got the impression the man was showing signs of "anxiety and depressed mood - suicidal ideation", he was referred to the psychiatrist.
The psychiatrist completed one assessment that day before the man returned the next morning with his parents for a follow-up assessment.
The psychiatrist concluded the man was experiencing a major depressive disorder with no imminent risk of self-harm.
He discharged the man, despite his parents holding misgivings, and suggested a follow-up GP appointment to treat his testicular pain as well as counselling in the community.
But after returning home with his parents the man was later involved in an incident that resulted in injuries causing his death.
Mr Allan's report found the psychiatrist failed to offer his patient ongoing specialist care, did not give his family enough information about his condition and did not adequately record in his clinical notes how he assessed the level of risk.
The commissioner recommended the psychiatrist undertake further training on how to communicate with patients and improve his clinical assessments, while also writing a letter of apology to the man's family.