"Had either or both of those things occurred, Leading Aircraftman Sargeant's death would've been prevented," Deputy State Coroner Naomi Kereru said.

Gary Dale Sargeant, 36, a "valued and loyal" leading aircraftman with the Royal Australian Air Force, was experiencing an acute mental health crisis when he died. He'd been posted to the cyber vulnerability investigation team at the Edinburgh base in Adelaide's northern suburbs in late 2019.

In findings handed down in South Australia's Coroner's Court, Deputy State Coroner Naomi Kereru said two "obvious" changes could've prevented Mr Sargeant's death. The first was an opportunity to search him when he was detained under the Mental Health Act. The second was having someone remain with him while he waited for an ambulance.

The inquest had heard Mr Sargeant had a history of mental health issues. The "introverted and quiet" man had reported experiencing social isolation, loneliness, and feelings of depression while working from home during the COVID-19 pandemic. In an early September visit to the health centre at Edinburgh, he'd told a nurse that when he was younger he would fantasise about suicidal acts.

Ms Kereru said an urgent referral was sent to independent psychologist Kathleen Mansfield, but she couldn't open the password-protected file when she saw him a few days later. "The failure to read this information highlights a lost opportunity to provide a perfectly timed intervention," she said in her findings.

She said Ms Mansfield's failure to read the referral before seeing Mr Sargeant was "inappropriate." She stated that the way she approached the case was "lacking" and that she'd "failed to provide the real engagement" Mr Sargeant sought.

On September 9, 2020, Mr Sargeant suffered an acute mental health episode, including symptoms of paranoia, and presented to the Joint Military Police Station and later the Edinburgh Health Centre. An ambulance was called, and Mr Sargeant was placed in a room which couldn't be locked.

He asked for a phone charger, and after a nurse went to find one he left the building and drove out of the base. During the inquest, counsel assisting the coroner Darren Evans told the court it took 22 minutes for Mr Sargeant's disappearance to be reported to military base police. It took an hour to work out he'd driven away in his car.

Ms Kereru said his absence couldn't be immediately reported due to technical issues with the phone lines. Mr Sargeant had left the base by the time the issues were resolved. "In light of the delay of the news reaching police, it took an hour to review all the relevant cameras for the period in order to determine that he had left," she said.

"The delay was compounded because no-one knew what car Leading Aircraftman Sargeant might have been driving." The inquest had heard his disappearance was reported to SA Police who asked for permission to release the photo from Mr Sargeant's ID pass. It was refused because he was in uniform.

Ms Kereru noted that the failure to provide the image occurred because there wasn't access to the computer system required to obtain the photograph at the time due to a coincidental system failure.

Mr Sargeant's body was found on breakwater rocks at Outer Harbor about 1pm on September 10, 2020. A post-mortem examination confirmed his cause of death as drowning.

Ms Kereru noted that before his death, Mr Sargeant had "longed to reconnect with his distant family." He never had the opportunity to realise that deep desire, Ms Kereru said.

She made multiple recommendations. These include that military and federal police be given the power to detain and search people with a suspected mental illness. She also recommended that military health facilities be fitted with a secure treatment space with visibility to safely house mental health patients waiting for transport for care.

She also recommended consideration be given to allowing other military members or civilians to transport to hospital when an ambulance was likely to be delayed.

Ms Kereru said had a chaperone policy been in place at the time, Mr Sargeant wouldn't have been left alone and "would have found it difficult to abscond."

Key Facts

  • Mr Sargeant's body was discovered on breakwater rocks at Outer Harbor, Adelaide
  • Mr Sargeant had a history of mental health issues
  • The inquest heard Mr Sargeant had told a nurse he fantasised about suicidal acts when he was younger
  • Ms Kereru said Ms Mansfield's failure to read the referral before seeing Mr Sargeant was "inappropriate"
  • An ambulance was called, but Mr Sargeant couldn't be found

Ms Kereru's findings have sparked a re-evaluation of mental health services in the Australian military. Many are calling for greater support and resources for those struggling with mental health issues.