The family of a Perth woman who died hours after she left a mental health clinic without psychiatric assessment say she was given inadequate care and her death was preventable.
Comic artist and illustrator Melanie Tregonning, 31, sought help from several health experts in the 48 hours before she took her own life in May 2014, the West Australian Coroner's Court heard on Tuesday.
"Her family are concerned that the medical assessment and care provided was inadequate and Ms Tregonning's death was preventable," counsel assisting the coroner Fleur Allen said in her opening address.
The court heard Ms Tregonning's father took her to the Keogh Institute at Sir Charles Gairdner Hospital, then she was seen by a general practitioner at Glenmoy Medical Centre where she was referred to a psychologist.
They returned to the centre later in the afternoon and were seen by another doctor, who determined Ms Tregonning needed an urgent psychiatric assessment, so she travelled by ambulance to Fremantle Hospital.
She reported contemplating taking her own life, having difficulty sleeping, trouble concentrating and crying occasionally, but there was no prior psychiatric history and no history of drug or alcohol use, the inquest heard.
Ms Tregonning was then sent to the nearby Alma Street Centre where she saw a nurse.
"There is some confusion between the witnesses as to whether this was for assessment or just to drop in the GP referral for outpatient follow-up," Ms Allen said.
"Although not formally assessed, Ms Tregonning was apparently relaxed and not distressed."
Ms Tregonning was sent home and her father found her dead the next morning.
The inquest continues.
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