Theo Nickolas Papageorgiou was a kind and generous man who would go out of his way to brighten up someone else's day.
When passing his neighbour digging into the garden dealing with pesky weeds, he'd take the task into his own hands, followed by a chat over freshly brewed coffee.
In the depths of a chilly winter in South Australia's Riverland, Theo insisted his grandmother turn the heating on, telling her not to worry because he'd foot the bill.
Once when behind the wheel on a long and lonesome regional road, he helped a young woman who had ran out of petrol 50 kilometres from the nearest town.
He took her to fill up a jerry can of diesel, and didn't leave her side until her car started.
Theo's dad, Jack Papageorgiou, thinks of his son every time he's driving along that road.
"I remember that this young man, my son, cared about people," he said.
"But when he needed help, help never came. That's what hurts."
A preventable death
Theo was 27 when he died from suicide in January 2016, after years of struggling with mental illness and failed attempts to seek medical help.
In the days before his death, Theo presented to the Riverland General Hospital in Berri but was sent home.
"When I have my 27-year-old son grabbing my hand, kissing it and saying, 'I love you Dad, sorry Dad', to me that was alarming," Jack said.
In 2021 a coronial inquest found Theo's death was preventable, he was misdiagnosed and his case was mismanaged by the health system.
"Given the inquest and the findings, who takes responsibility for Theo's mismanagement?" Jack said.
"Let's face it, the system is failing."
Better access to patient records
Theo's case significantly contributed to the South Australian Law Reform Institute's (SALRI's) review of the Mental Health Act 2009 (SA), which was handed to the state government on March 19.
Decisions around Theo's medication and treatment were made without an understanding of his complete mental health history, and the inquest found this lack of clinical file sharing to be a contributing factor to Theo's death.
"There's got to be transparency, there's got to be better communication in the health system," Jack said.
The review's lead author Olga Pandos said information sharing issues were particularly problematic for regional, rural and remote hospitals and services.
"We've made recommendations to the government to explore better alternatives for information sharing across Local Health Networks so patient records can be accessed more easily," she said.
'Clear disparity'
Theo sought treatment for his mental illness from a range of service providers in the Riverland, but the inquest found there was inadequate continuity of care partly due to an understaffed and transient workforce.
These concerns were echoed throughout the SALRI's community consultation, with Ms Pandos hearing about significant issues for regional people accessing mental health services.
"We found there was a shortage of medical specialists to see, there are wait times and costs," she said.
"There's a clear disparity in relation to mental health services in metropolitan versus regional centres.
"We've specifically asked the government to further review and investigate resourcing and staffing — relating to retention of staff and resident specialists — infrastructure and funding of regional, rural and remote mental health services," she said.
Improving a 'broken system'
Health Minister Chris Picton said the state government was now carefully considering the 61 recommendations and 11 suggestions in the SALRI's independent review.
The government will undertake further consultation with key mental health stakeholders and consumer groups before bringing new proposed legislation to parliament.
"I have met with Jack and [his wife] Poppy several times and appreciated their insights on how we can improve mental health systems," Mr Picton said in a statement.
"I'll be keen to meet with [them] again as we undertake that work."
Jack said it had been his family's aim since 2016 to help create a better mental health system, and he wanted to see all of the recommendations and suggestions implemented.
"It's critical that members of parliament listen to people on the ground and take that on notice to improve a broken system," Jack said.
But as they fight to improve the lives of regional people, Jack and his family never cease to honour Theo's memory, and find happiness in life.
"Theo was the first child in our lives, and he brought us plenty of joy," he said.
Jack pulls out his phone and looks at a photo of his grandchild, who bears a name in his late son's memory.
"Our daughter sends us photos and videos of him," Jack said.
"When I go to Adelaide, I just hold him.
"That's what gives me relief and a joy that I do have a son with me again."
