A South Australian coronial inquest has found the 2020 death of Royal Australian Air Force serviceman Gary Sargeant could have been prevented on several occasions while he was experiencing a severe mental health episode. Deputy State Coroner Naomi Kereru said failures including not searching him, not removing his car keys, and leaving him unsupervised while waiting for an ambulance contributed to his disappearance from Edinburgh RAAF base near Adelaide. Mr Sargeant, a 36-year-old leading aircraftman and cyber specialist, was later found drowned at Outer Harbor. The coroner recommended major reforms to military mental health procedures, including secure treatment spaces and mandatory supervision policies for at-risk patients.