The man, who Australian Community Media can only identify as 'Mr O', was 47-years-old when he committed suicide at Dimboola in July 2017.

The man's mother considers her son was "let down" over the care Grampians Health provided to her schizophrenic son in Ballarat.

In 2021, a Victorian coroner found there were "significant" issues in the care provided to Mr O, who came into contact with mental health service triage six months before his death.

Coroner Sarah Gebert said the issues included the health service's response was largely driven by contact from Mr O's family, it failed to engage with Mr O's partner and extended periods of time passed without contact between the treating clinician and Mr O.

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The coroner found the community treatment plan took longer than allowed and there was minimal contact with Mr O over the 13 weeks to prepare the plan.

Ms Gerbert said Mr O's family and friends recognised he was unwell, and his parents had made considerable effort to have him assessed and treated.

She said Mr O was likely to have been suffering from schizophrenia for some time and he was not always willing to engage as a voluntary patient.

Ms Gebert made two recommendations to Ballarat Health Services, now known as Grampians Health.

The recommendations include BHS develop a specific policy or procedure to address the importance of actively engaging family and responding to family concerns, consistent with the Victorian Chief Psychiatrist's guideline "Working together with families and carers", published in August 2018; and that BHS ensure their procedure entitled "Persons who are difficult to engage" incorporates information about the important skills that are required for these patients and ensure that staff are afforded training opportunities to improve their confidence and skills when working with difficult-to-engage patients.

"I note that the BHS have instituted or are instituting many changes, which are in direct response to those issues and concerns raised by Professor (Richard) Harvey," Ms Gebert said.

"I also acknowledge the ongoing concerns regarding the recruitment and retention of staff which is experienced in rural areas."

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The Coroners Court of Victoria Recommendations Report, released on Tuesday, shows Grampians Health response to the recommendations is overdue.

The health service was expected to respond by February 10.

However Grampians Health - Ballarat said in a statement it was confident it had implemented both recommendations made by the Coroner's Court.

"We are working with the court office to ensure that their records are updated to reflect the new 'Working with Families and Carers' policy and updated 'Persons who are difficult to engage' procedure," Grampians Health - Ballarat said.

Grampians Health - Ballarat will be speaking to The Courier next week to discuss progress being made in mental health services across the region, and the impacts of the Royal Commission into mental health.

If you or someone you know is in need of crisis support, phone Lifeline 13 11 14.

Help is also available, but not limited, via the following organisations. The key message is you are not alone.

Beyond Blue 1300 224 636 or beyondblue.org.au

Suicide Callback Service: 1300 659 467

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