Linden Kunoth, 24, and Jordan Allen, 34, died by suicide while in the care of the Alice Springs mental health ward.

Key points: Two men died by suicide in 2017 and 2018 after being granted leave from the Alice Springs Hospital

Two men died by suicide in 2017 and 2018 after being granted leave from the Alice Springs Hospital NT coroner found the decision to release one patient failed to "properly appreciate the risks"

NT coroner found the decision to release one patient failed to "properly appreciate the risks" Linden Kunoth's family said they had not been properly briefed on how to care for their relative

Both men had been involuntarily admitted to hospital and were on temporary escorted leave from the ward under the supervision of their parents when they died.

The inquests into both deaths found that neither man should have been granted leave and recommended that the hospital improve its escorted leave procedures.

At issue in both cases was the function and use of the hospital's leave approval forms, which required both the signature of a doctor and the signature of the escorting carer.

The forms are also intended to document the conditions of a patient's leave.

On October 13, 2017, Mr Kunoth was involuntary admitted to Alice Springs Hospital following suicidal ideation with suspected drug-induced psychosis.

Four days later, he was granted escorted leave from hospital with his family on their request.

Later that day, Mr Kunoth took his own life in an Alice Springs town camp.

Mr Kunoth's family submitted written evidence to the inquest that they were not properly briefed on how to look after their son while he was in their care.

The family's signature was absent from the escorted leave form.

According to the inquest's findings, the Alice Springs Hospital had no approved procedures in place for granting leave.

During the inquest, Mr Kunoth's treating doctor Ramesh Chandran told the coroner that "it was just a piece of paper" and that he thought that the carer's signature was not important.

The coroner found that a lack of procedures had a "significant impact" and that it was not surprising the importance of the form was "not understood".

The coroner also found, given Mr Kunoth's condition, the decision to grant him leave was "due to either a failure to properly appreciate the risks or a willingness to take those risks".

"It seems that safety was not the first consideration in either scenario," the coroner found.

Procedures ignored carers' concerns

Three months later, on January 29, 2018, Mr Allen was admitted involuntarily to the Alice Springs Hospital.

He repeatedly expressed a desire to leave the hospital and was experiencing unpredictable psychosis.

Two days later he was given 15 minutes of escorted leave to have a cigarette with his father. During that time he ran away and took his own life.

Both men died in Alice Springs after being granted supervised leave from the hospital. ( Alice Springs Town Council )

The coroner told the inquest it was clear that Mr Allen's father had done all he could to protect his son.

Following Mr Kunoth's death, the coroner found that the hospital had updated its procedures but they did not adequately give carers space to voice concerns.

"His father understandably had significant reservations. It was only a few days before that he had managed to get Jordan to the hospital," wrote the coroner in his findings.

The coroner said that Mr Allen's father had been in an "impossible" and "tragic" position.

His father told the inquest that he had been apprehensive about his son being given leave, and the coroner found that his treating team had not sought to understand his concerns.

His father had also been given no advice about what to do should his son run away.

The Central Australian Health Service told the coroner forms and procedures were under review.

The coroner found that the service had "put a great deal of effort into attempting to modify their systems following the deaths of Jordan and [Mr Kunoth]."