An inquest into the suicide of a 15-year-old schoolboy has exposed "shortcomings" in South Australia's mental health service for young people, a coroner has found.
Deputy State Coroner Anthony Schapel on Tuesday delivered his findings into the death of Jason William Hugo-Horsman at his Mount Barker home in October 2010.
Jason attended the Child and Adolescent Mental Health Service (CAMHS) in Mount Barker where he saw a social worker from February 2010 to August that year.
The coroner said the social worker was Jason's sole therapist "for an unduly extended period of time" and a psychiatrist should have been called in to help the teenager.
"The CAMHS structure has been shown to be bottom heavy in that it is unduly reliant on the efforts and skills of social workers," he said.
"This case has demonstrated that the psychiatrist needs to be brought into and retain close oversight of the management of a patient at an earlier time, especially when risk of self-harm or suicide has been identified as it was here on two separate occasions."
Mr Schapel also found that CAMHS showed a lack of awareness of the current understanding of the risks and benefits associated with prescribing anti-depressant medication to adolescents.
He said CAMHS should have told Jason's parents that he had experienced low moods to the point of crying and cutting himself on Saturday evenings when they were absent.
His father told the inquest he had believed it was of benefit for Jason to have time to himself and he had not appreciated there was any risk of him being left alone on Saturday evenings.
"Jason's death may have been prevented on 9 October 2010 had that particular scenario been avoided, Mr Schapel said.
"However, it cannot be said with any degree of certainty that Jason's suicide may have been prevented altogether."
The coroner made a number of recommendations including that it be mandatory for a client to be referred immediately to a CAMHS psychiatrist in the event of any suicidal ideation and/or self-harm.
He also said new clients should be assessed in person, rather than through a telephone referral.
* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or Kids Helpline 1800 55 1800 (for young people aged 5 to 25).
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