Philip Cristallo was seeking a lifeline when he walked into the mental health unit at Canberra Hospital.
Instead, he felt as though he stepped into a "fishbowl" trapped in an environment he says is hostile.
Patients at the Adult Mental Health Unit (AMHU) say they were left at risk after being discharged prematurely, while children were admitted alongside acutely unwell adults despite there being a dedicated youth ward.
The Canberra Times spoke to several people that said the hospital failed to provide adequate support to both mental health patients and their parents.
Mr Cristallo was admitted to the unit in 2014 after he attempted to take his own life and was readmitted a year later for about two weeks.
During an argument over a knee brace he was wearing when admitted the second time, he alleges staff members took him into a side room, ordered him to remove his clothes, restrained him and injected him with a sedative without an explanation.
Several hours later, he said he had an allergic reaction to the sedative.
"It felt like my muscles were crushing my bones, and I could barely expand my lungs," he said.
Mr Cristallo said that he crawled to the nurses' station before collapsing. He was told by other patients it took about 15 minutes for nurses to assess him.
He said the experience left him so distressed he was unable to file a complaint.
Shortly after the allergic reaction, he alleges he was discharged without papers. When he later requested them, there was no record of the allergic reaction.
"They were so quick to push me out. I did not feel like I got any assistance with what I actually needed support for," he said.
"I'm not saying the nurses do a bad job because they do all that they can. They go through like legitimate hell while they're there."
A month after Mr Cristallo was discharged, his mental health deteriorated and it was recommended he be readmitted for further support.
"I begged them not to send me to AMHU, I was breaking. I literally broke down into tears," he said.
Taking into account his concerns, the assessment team decided to admit him to a unit at a different hospital.
AMHU opened on March 23, 2012, and is located at the Canberra Hospital in Garran. It now offers 40 beds, split between a high and low dependency unit for adult short-stay patients.
The child and adolescent mental health unit at the hospital provides care for patients aged 12 to 18 years, with a capacity of six beds.
Emma Ford said she has not been given an explanation for why her 16-year-old daughter was admitted to the adult ward when she had a mental health crisis in February this year.
Ms Ford alleges her teenager was excessively sedated multiple times during her stay at the unit, and was not allowed to contact her family members.
"If I wasn't supporting my daughter, then she probably would have been dead," Ms Ford said.
She alleges when her daughter was discharged without papers she was left without adequate ongoing support: the hospital did not check in, provide a counselor or any ongoing treatment.
"They just basically chuck them on the street," Ms Ford said.
Her daughter was readmitted by ambulance later that night.
"It's just a continuous thing. She got put in there. They'd sedate her, not help her, no follow ups," she said.
A spokesperson for the Canberra Health Services said they were unable to comment on individual cases for privacy reasons.
"The decision to place a young person (under 18) in AMHU is only made when necessary and is done in consultation with the young person, family/carers and CAMHS specialists," the spokesperson said.
The independent government reviewer, Official Visitors, said in its most recent annual report that the issue of children being admitted to the adult ward has been reported in the quarterly reports for the last three years.
Their analysis of complaints against the hospital said that "this practice can result in further trauma and the worsening of young people's condition".
ACT Public Advocate Jodie Griffiths-Cook said she has raised concerns to the unit about the admission of young people into the adult ward multiple times.
She said young people are "feeling unsafe amongst adults who are acutely unwell and feeling isolated from others of their own age".
Ms Griffiths-Cook said this may result in young people being discharged before they are stabilised, placing them at a higher risk of readmission.
About one in eight acute mental health patients in the ACT are readmitted to hospital within 28 days of being discharged, according to the Australian Institute of Health and Welfare's most recent data.
"The majority of readmission cases in the ACT relate to a small number of consumers who can experience frequent acute episodes of mental ill health," a Canberra Health Services spokesperson said.
Minister for Mental Health Dr Marisa Paterson said: "I take any concerns raised about a patient's care seriously."
Ms Paterson said she encourages patients, families or carers with concerns to contact Canberra Health Services Consumer Feedback or their treatment team.
After nearly a decade, Mr Cristallo walked back into AMHU to visit a recently admitted family member. The shivering experience left him concerned that the unit "felt even more institutional" than when he was a patient.
"I just felt the fishbowl experience again but this time it was worse because there was a lot of security and it felt more like a prison than where you get better."
He said staff and patient safety is important, but the environment is distressing and concerning for mental health patients today.
He said his family member left the hospital saying he never wants to end up there again, after an experience that was far too familiar to Mr Cristallo.
