A man "deliberately" fell from a balcony just days after he was discharged from a mental health unit without sufficient support, a coroner has found.
Mitchell Follent died on August 20, 2016, after "deliberately leaning over and then falling from a third floor balcony head first, landing on his head", the coroner said CCTV footage showed.
His mother, Julie Josey, told Brisbane Times, her son was the kind of man who would help neighbours to the front door with their groceries.
"He was very kind and generous young man, he was well-mannered and well thought of," she said.
Mr Follent, 22, grappled with mental health issues for years before his death. He also endured regular seizures as a result of a brain injury he acquired when he was six years old.
Ms Josey said her son used to smoke marijuana often, believing it was curing his seizures.
It was marijuana that triggered a psychotic episode that saw him admitted for a 10-day stay at the Ipswich Hospital Mental Health Unit on August 5 2016.
He was discharged five days before his death, without proper support or planning, an investigation found.
An investigation by the West Moreton Hospital and Health Service found that despite a number of risk factors, his "risk for suicide, self-harm, aggression, vulnerability and absconding were assessed as low".
Because of Mr Follent's complex medical history case, a more comprehensive assessment should have been done before he was discharged, the health service's investigation found.
Upon his release, a follow-up with an acute care team should have been organised to help Mr Follent begin a regular dose of antipsychotic medication, given he had not been taking his medication "and preferred to use cannabis".
There had also been a delay in forwarding his discharge summary to the GP.
His mother, and primary carer, said she was excluded from all planning and the hospital did not even notify her that he had been discharged.
"There was no plan for his discharge, his GP wasn't even told, I wasn't even told, I wanted him to stay in there because he needed more support," Ms Josey said.
"He was living alone, was not compliant with his medication and he had the mental age of a 14-year-old, but they just took him at face value and did not review the decision to discharge him with me.
"There was no follow-up, he should've had a team looking after him, he should have had appointments made for him to come back in and check on him after his discharge."
Ms Josey said her son was regularly visited by NDIS workers before his hospital admission, though his deteriorating condition was not flagged.
"He began to behave really strangely, he was hacking off chunks of his hair with scissors, but nothing was escalated," she said.
"What training and alert processes do these carers have to escalate an issue when they notice someone's behaviour is changing?
"It is appalling. Nothing was done. All of these agencies could have flagged this earlier, maybe the hospital would have taken us more seriously. It was the holes in the Swiss cheese lining up."
The hospital's investigation found "Mitchell was discharged in the absence of sufficient support, when he was not able to safely self-care, which increased the likelihood of poor adherence with medication".
"This was a complex case which presented many opportunities for assessment and intervention, as well as providing many missed opportunities."
An open disclosure meeting was held in 2017 with Ms Josey, after the investigation had wrapped up.
'The hospital acknowledged at the meeting there were a number of interventions that were not performed to the expected standard."
Adequacy of discharge planning and a lack of mental health follow-up after discharge had already been flagged by the root cause analysis team.
The coroner's court was advised the health service had already adopted two recommendations to ensure better discharge planning for mental health patients.
But Ms Josey is not confident, saying an "extreme lack of communication" had contributed to her son's death.
"They are going to have a review of the review – what a load of crap. I was very angry and very upset, I still am because I don't see that anything has changed.
"You just feel like you are beating your head against a wall, nothing ever changes. I don't want him to have passed away in vain and nothing be done; it actually shouldn't take some to pass away for something to be done," she said.
"I want people to know this isn't the first time this has happened and it will continue to happen."
"In those circumstances, although Mitchell’s action were always likely to end his life, I am unable to determine whether Mitchell had capacity at the time to form an intention to take his own life," he found.
Lifeline 131 114; beyondblue 1300 22 46 36.