Michelle and Malcolm Peck's son Edward took his own life in August 2015, just hours after he was discharged from the Royal Hobart Hospital.

Key points: Edward Peck took his own life in 2015 just hours after being discharged from hospital at his own request

Edward Peck took his own life in 2015 just hours after being discharged from hospital at his own request Psychiatrists say Tasmania's Mental Health Act makes it hard for clinicians to take past mental health issues into account, which puts patients at risk

Psychiatrists say Tasmania's Mental Health Act makes it hard for clinicians to take past mental health issues into account, which puts patients at risk The act is under review, and Edward's family want it to be overhauled

"He was a kind, funny, normal 23-year-old Tasmanian that we needed to look after and we didn't," Mr Peck said.

Edward had been admitted to hospital after an incident of self-harm, requiring surgery.

He had a long history of mental illness and had made two suicide attempts that weekend.

Despite his mother explaining this to hospital staff and begging for her son to be involuntarily detained, Edward was discharged on the afternoon of August 10 at his own request.

Coroner Olivia McTaggart's findings into the Hobart man's death reveal his community psychiatrist also expressed her concerns about Edward's safety to the Royal.

His psychiatrist, Dr Ait Khelifa, telephoned a fourth-year psychiatry registrar at the Psychiatry Consultation Liaison Team at the RHH, requesting Edward remain at the hospital for further treatment.

Mr Peck said his son should not have been released from the Royal that day.

"It was an opportunity to keep him safe from himself and that is society's obligation, to keep the vulnerable people safe," he said.

Malcolm and Michelle Peck say Tasmania's mental health system failed their son. ( ABC News: Rhiana Whitson )

Parents call for overhaul of Tasmania's Mental Health Act

Tasmania's Mental Health Act was changed in 2013, making it harder for clinicians to involuntarily admit patients.

Instead, the focus is on the patient's capacity to make decisions about their own treatment at that particular point in time.

One psychiatrist told the ABC the change to the Act meant some patients who previously would have been held on an involuntary order were now being released without their history of self-harm taken into consideration.

Mr Peck said the Act must be overhauled because it failed their son.

"It is important for the next person who has capacity and walks into the Royal and decides 35 minutes later that he doesn't have that capacity and does something terrible to himself."

Staffing conditions at the Royal 'drastically inadequate'

Coroner McTaggart did not attribute any blame to any particular individual at the Royal, however she did note the community psychiatrist should have been consulted before Edward's discharge.

Coroner Olivia McTaggart identified a lack of psychiatric staff at the Royal as a problem. ( ABC News )

Instead, she identified under-staffing in the Royal's Psychiatry Consultation Liaison Team, and recommended a review of staffing at the Royal.

On the day of Edward's death, there was only one psychiatrist, Dr David Lang, working on the roster, along with the equivalent of 1.5 full-time registrars, supported at times by a psychiatric emergency nurse.

Dr Lang gave evidence that in the UK, for a catchment area the same size as Hobart, the recommended size of the team would be one to two consultants, up to two registrars, five psychiatric nurses, an administrative assistant and a social worker or psychologist.

"The fact that he (Dr Lang) is required to perform his valuable public service in such drastically inadequate conditions signifies his dedication."

In a statement, Health Minister Sarah Courtney said the state government would consider the coroner's findings.

Mental Health Review to begin later this year

The State Government said a review of the Mental Health Act is underway with public submissions open until November.

Former health minister Michael Ferguson said he was sympathetic to the views expressed by the Pecks.

"These kinds of pieces of feedback will absolutely need to contribute to the consultation as the act itself is reviewed, because capacity is vitally important but so too is the advice and support of a family," he said.

Mr Peck hopes other families will be listened to.