A teenager who took her own life should have been referred to a psychiatrist by a social worker involved in her case, a coroner has found.
South Australian coroner Mark Johns has also criticised the operations of the Child and Adolescent Mental Health Services (CAMHS) describing the organisation's structures as fundamentally flawed.
He says the CAMHS social worker who saw 15-year-old Michaela Mundy should have referred her to a psychiatrist given the seriousness of her depression and her suicidal thoughts.
"Had her condition been properly treated earlier, Michaela would have had a better chance of not proceeding to severe major depression and would have had a better chance of recovering," Mr Johns said.
The teenager was found dead at her mother's Adelaide home in July, 2012.
She had been suffering from anxiety and depression for some time and had been treated by the social worker as well as a GP with a special interest in mental health issues and a psychologist.
In his findings, Mr Johns called for CAMHS to have more psychiatrists to cope with the patient load and for the organisation to be restructured to reflect the importance of the service it provided.
"If the service were, for example, surgical, it would be provided in a hospital under the clinical supervision of a consultant," he said.
"In the case of CAMHS, the service is not being provided in a building called a hospital, but the importance of the service is of the same order.
"The errors in this case and Michaela's tragic death amply demonstrate that."
* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14, or Kids Helpline on 1800 55 1800.
