The death of an Adelaide man who was strangled by a fellow psychiatric patient while in hospital came amid a "certain inevitability" of an incident of this type, a coroner has ruled.
Stephen John Barton, 43, was killed after being attacked by Lindon Sekrst in the room the pair shared at the Noarlunga Hospital in August 2014.
In his inquest findings on Tuesday, Deputy State Coroner Anthony Schapel said while there was no overt indication Sekrst would harm anyone, he described the practice of placing two people in the same open ward as "highly undesirable".
"There seems to have been a certain inevitability in an incident of this kind occurring at some point in time," Mr Schapel said.
"It was not so much a question of whether such an incident would occur and when, but to whom."
The coroner said dual occupancy was particularly troubling when little was known about the background of a newly admitted patient.
"It is also especially so when it is believed that the newly admitted patient is experiencing paranoid ideation and where routine checks on that patient are spaced as far apart as an hour," he said.
Mr Schapel recommended that dual occupancy in psychiatric wards in public hospitals in South Australia no longer be permitted.
During the inquest, Mr Barton's family also called for distress alarms to be issued to patients and raised concerns about the assessment of Sekrst before he was assigned the room.
"We believe patients should be completely diagnosed prior to them being placed in a shared room," Mr Barton's sister Glen Westerhoff said.
Sekrst was originally jailed for murder but appealed and later pleaded guilty to manslaughter.
