A man who attempted to take his own life in the toilets of the Royal Hobart Hospital's emergency department waiting room was unable to get immediate medical attention despite experiencing thoughts of self harm, an inquest has heard.

Key points: Joseph Aaron Lattimer died days after trying to take his life in a hospital toilet

Joseph Aaron Lattimer died days after trying to take his life in a hospital toilet He had been waiting for treatment at the Royal Hobart Hospital

He had been waiting for treatment at the Royal Hobart Hospital Mr Lattimer's parents described their son as "precious" person

Joseph Aaron Lattimer was 37 when he died in July 2016, several days after the incident which resulted in him being placed in an induced coma in the hospital's intensive care unit.

The inquest heard the Hobart man, who suffered with alcohol addiction and mental illness, had made a triple zero call to police, telling them he was experiencing "serious self harm thoughts and needed to speak to someone".

"Everything's gotten on top of me, I've got to get help before I do something stupid," Mr Lattimer told police in the call played to the court.

Quietly seated at the rear of the court room, Mr Lattimer's family wept and hugged each other while hearing his voice.

Mr Lattimer's parents described their son as a "precious" person who "had to fight with his loneliness and everything against him".

Coroner Olivia McTaggart warned Mr Lattimer's mother, father and sister the three day inquest "would not be easy to sit through".

Coroner McTaggart said she had called the inquest because she had identified potential staffing and supervision deficiencies, concerns of non-adherence to hospital guidelines and wider issues with the hospital system.

Andrew Sculthorpe, the paramedic on duty that night, told the inquest that in his time as a paramedic he had waited up to 10 hours and foregone mandatory breaks while ramped with hundreds of mental health patients who had waited to be admitted to hospital.

Mr Sculthorpe said Mr Lattimer was calm, compliant and non-threatening while he was taken from his family's Mornington home by ambulance to the emergency department in the early hours of July 10, 2016.

He told the hearing Mr Lattimer had brought a book to read while he waited to be seen.

The inquest heard there was no space to accommodate Mr Lattimer at that time and two other patients were also waiting to be seen by medical staff.

Counsel assisting the inquiry Simon Nicholson said Mr Lattimer was triaged as a category three out of five, meaning he urgently required treatment within 30 minutes of presenting to the emergency department.

Patient found 'blue and lifeless'

The only triage nurse on duty at the time was monitoring him via visual checks every five to 10 minutes.

She had her back turned to the waiting area while she triaged another patient, and later noticed he was no longer in the waiting area at about 5:50am.

After looking for him outside, another patient informed her Mr Lattimer had gone to the toilet.

It was there that Mr Lattimer was found "blue" and "lifeless" at about 6:30am.

Mr Sculthorpe, who had returned a short time later with another patient, said he was "taken aback" to learn what had happened.

The inquest heard patients with a mental health crisis were now accompanied when going to the toilet or outside. ( ABC News )

"We thought we'd done quite well by removing him from his plan [to take his own life], so it was quite a shock to us," he told the inquest.

Mr Sculthorpe said there had been significant procedural changes made in the wake of Mr Lattimer's death.

He said patients experiencing mental health crises were now ramped in corridors with paramedics supervising them closely until they received treatment.

They were also accompanied to the toilet and outside for cigarettes, he said.

When Mr Lattimer went to the emergency department there was no psychiatric emergency nurse or clinical initiatives nurse on duty or available.

The three-day inquest will investigate how caregivers responded to his request for help and whether further changes are needed.