Peter Zovak's brother begged ACT Mental Health to get help for his severely depressed, hallucinating, despondent sibling six days before he eventually took his life.
But his desperate pleas for assistance, made less than a month after his brother was released by Canberra Hospital's mental health workers, fell on deaf ears.
"They said 'no, no, no, I don't think that's a mental health issue, tell him to see his GP'," his brother Ned Zovak told a coronial inquest on Wednesday.
"I said [to Peter], sorry mate I can't get you any help today.
"The look of devastation on his face will live with me forever."
Peter Zovak committed suicide less than a week later.
The Zovak case has raised questions of serious failings in the ACT mental health system, now being looked at by Chief Coroner Lorraine Walker.
Peter Zovak was already known to the mental health crisis assessment and treatment team, or CATT, by the time of his brother's call on December 12 last year.
A regular cannabis user, he began to experience worsening hallucinations and depression for the first time the month prior.
His brother, highly concerned at the deterioration, took him to the Canberra Hospital.
He was assessed twice and, after improvements, was discharged, with CATT workers responsible for reviewing his case.
Mental health staff had been told that Peter Zovak's condition was fluctuating and his mood subject to change in a matter of days.
A doctor at the hospital recommended two face-to-face visits with the man at his home to keep tabs on his condition.
Only one of those visits was ever conducted.
During that 15-minute visit, Peter Zovak told them from his driveway that he felt fine, and appeared to have improved and to be free from any risk of self-harm or suicide.
Instead of a second visit later that week, CATT staff called him the very next day, in which he again claimed to feel fine.
No effort was made to contact his family, including his brother, despite the fact he was the first to have raised the alarm with mental health services when he brought Peter Zovak to hospital the month prior.
Instead, they decided to cease contact with the client, later closing his file.
His brother, when he later called CATT in a state of desperation on December 12, would tell them he had not improved since his hospital visit three weeks earlier.
The CATT worker who took the call gave evidence to the inquest on Wednesday, claiming Ned Zovak had never pleaded for them to send help.
"In my view, that discussion never happened," he said.
He said he didn't recall Ned Zovak telling him his brother hadn't slept for a week, and claimed he agreed to send his sibling to a GP before CATT would become involved.
That's despite Peter Zovak not having a regular GP, or even a Medicare card, according to his brother.
Under questioning by Zovak family barrister Wayne Sharwood, the worker agreed he may have now done things differently.
"Looking back now, I may have put the phone call as a follow-up phone call for the next day or day after," he said.
The worker claimed he was limited in his response because Peter Zovak did not want help from CATT.
That assumption was based on the client's attitude during the home visit and phone call the month prior, when he told staff he didn't need their help.
But Ned Zovak gave evidence that he told the CATT worker his brother liked CATT staff and favoured their help over the prospect of going back to the hospital, where he feared he would be locked up in padded cells.
"He just wanted to shove me off straight away to a GP," he told the inquest.
Counsel assisting Sarah McFarland, Mr Sharwood, and lawyers for the ACT government will now submit written submissions to the inquest.
Chief Coroner Walker told the inquest she may decide to issue notices of adverse findings.
Her findings will be handed down at a later date.
Lifeline 131 114
