The territory's mental health system failed a Canberra man who died by suicide days after his brother begged for professional help, an inquest has found.
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But Chief Coroner Lorraine Walker said Peter Zovak's death could not be directly linked to the "inadequate" care he received in the lead up to his death.
But his desperate pleas for assistance, made less than a month after his brother was released by Canberra Hospital's mental health workers, fell on deaf ears.
"I said [to Peter], 'Sorry mate I can't get you any help today'," Ned Zovak said.
"The look of devastation on his face will live with me forever."
Peter Zovak died less than a week later.
He was already known to the mental health crisis assessment and treatment team, or CATT, by the time of his brother's call on December 12.
Mr Zovak was a regular cannabis user and began to experience more severe hallucinations and depression for the first time the month prior.
His concerned brother took him to Canberra Hospital where he was later discharged after some improvements.
Later that week Mr Zovak told CATT workers he felt fine.
No effort was made to contact his family, including his brother, despite the fact he was the first to have raised the alarm with mental health services when he brought Peter Zovak to hospital the month prior.
Workers decided to cease contact and later closed his file.
When his brother made a desperate call to CATT on December 12 he told them he had not improved since his hospital visit three weeks earlier.
The CATT worker who took the call gave evidence that Ned Zovak had never pleaded for them to send help.
He said he didn't recall Ned Zovak telling him his brother hadn't slept for a week, and claimed he agreed to send his sibling to a GP before CATT got involved.
That was despite Mr Zovak not having a regular GP or a Medicare card.
The worker said during the inquest he may now have acted differently and claimed he was limited in his response because Peter Zovak did not want help from CATT.
In findings published on Tuesday, Ms Walker found Peter Zovak did not receive an adequate level of care.
But she made no connection between ACT Mental Health's failures and Mr Zovak's death and said any link between the two would be speculation.
Ms Walker offered her condolences to Mr Zovak's family members and said the community should continue to be vigilant to "the hidden social affliction" of suicide, its causes and its aftermath.
She said the decision by mental health workers to close Mr Zovak's file wasn't unreasonable at the time.
But the service's failure to respond to the call for help in December wasn't reasonable and the information given in Ned Zovak's phone call on December 12 was "strongly indicative" of ongoing mental health issues, she said.
She said the worker who took the call made a serious error of judgment and while the call was a lost opportunity, it was "entirely speculative" what difference a more proactive response would have made.
The Chief Coroner did not make any formal recommendations but suggested ACT Mental Health consider measures that would allow staff to share information with a designated family member or carer.
She also suggested the service review the CATT team's role to consider whether it was best structured to meet the community's needs.
An ACT Health spokesman welcomed the suggestions and said the mental health service was reviewing processes for information sharing with carers and family members.
The spokesman said the service would continue to review and update procedures in line with an internal action plan on mental health triage that began after the incident.
That included a review of staff training and the addition of a second triage worker.
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