Perth's main mental health facility at Graylands Hospital is outdated, overcrowded and lacking resources.
Those are some of the conclusions after 10 inquests into the deaths of hospital patients over seven years revealed tragic insights into the plight of WA's mentally ill.
Coroner Barry King described the life of one patient, who spent more than 20 years at the hospital because she had nowhere else to go, as an "unmitigated tragedy".
While no systemic issues were found to link the deaths, major lingering issues with the ageing hospital were repeatedly highlighted.
They included overcrowding, lack of privacy for patients, unsuitable facilities, no alternatives for difficult cases, and boredom for long-term patients.
Debora Colvin, head of mental health advocacy group the Council of Official Visitors, said the conditions in some of Graylands' wards were "dire".
"We find ourselves in this very strange place of people banging at the door to get into mental health services, with people at the other end banging to get out . . . but with nowhere to go," Ms Colvin said.
The multiple inquests were called to investigate the suitability of the 172-bed hospital for those with complex needs, methods for dealing with patients who abscond, services for Aboriginal patients, and the suitability of the physical environment at the hospital - WA's biggest for mental health inpatients.
In all but one of the cases, the care provided for those who died was found to be reasonable and appropriate. But concerning themes about the facility emerged throughout.
In the case of Aaron Prisgrove, a 32-year-old who hanged himself while being treated at the hospital, Mr King said staff at Graylands were fighting an uphill battle. "Staff at facilities such as Graylands must deal with the dilemma of managing difficult and unpredictable patients in the least restrictive manner possible, while protecting them from self-harm," Mr King said. "It is difficult to see how it can be possible to do both successfully with the resources available."
The case of 47-year-old Amanda Gilbert, who had spent almost half her life in Graylands - despite evidence she had been assaulted more than 100 times by other patients - highlighted the lack of treatment options.
Mental Health Minister Helen Morton said the State Government was "seriously considering" the future of Graylands.
If you or someone you know is thinking of suicide phone Lifeline on 13 11 14