Mental health patients are being forced to wait for up to a week in Adelaide emergency departments because of a shortage of beds.
An annual report by South Australia's Community Visitor Scheme - which advocates for mentally ill patients - has also raised concerns about excessive shackling.
One forensic patient was chained and handcuffed to a bed for five days while under heavy guard.
"He seemed to be a gentle man who was missing his mother," the report said.
"He was somewhat confused and wasn't certain how long he had been in ED or if he had seen a doctor."
Another "confused, frustrated and homesick" patient said the hospital was "like a jail" and that she felt unsafe.
One patient was left in an emergency department for a week because no mental health beds were available.
Another sat in a waiting room chair for 16 hours, leaving his family "extremely upset".
Mental Health Minister Jack Snelling in October announced 21 new beds to reduce the wait times for mentally ill patients.
He has pledged that no patient will be "routinely" waiting in emergency for a bed for more than 24 hours by 2016.
Wait times were exacerbated by patients who remained in hospital because they had nowhere to go, the CVS said.
One patient only left the hospital for 26 days over a two-year period.
Another was discharged without clear accommodation options.
