A Fremantle mental health service is in the spotlight after five patients who had been in and out of treatment took their own lives.
An inquest in the Coroners Court of Western Australia is examining the deaths of Stephen Colin Robson, 47, Ruby Natasha Nicholls-Diver, 18, Michael Ronald Thomas, 57, Anthony Ian Edwards, 26 and Carly Jean Elliott, 20.
All had attended Alma Street Clinic between March 2011 and March 2012.
In opening addresses on Tuesday, the court heard Mr Edwards was a promising teen golfer who planned to make the sport his career, but became involved with people who introduced him to cannabis and amphetamines, which triggered a psychotic episode.
He formed a strong and positive relationship with a doctor, and his life was back on track for several years until December 2011 when his medication was changed.
By mid-March the following year, he had suffered a relapse and was admitted as an involuntary patient.
But days later, he was discharged and jumped from a building.
The inquest will look at matters including his change in medication and the circumstances surrounding his discharge.
The court also heard that Mr Robson stepped in front of a truck after sneaking out of the hospital while Ms Nicholls-Diver was discharged despite having tried to hang herself in the clinic.
As well as examining each of the five cases, the inquest will also seek to answer general questions about WA's progress in implementing changes recommended in neurosurgeon Bryant Stokes' 2012 review into the state's public mental health services.
Professor Stokes, now WA's acting director general of health, will be called as an expert witness.
Former and current chief psychiatrists will also be called.
* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or Suicide Call Back Service on 1300 659 467.
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