Monash Health has accepted a non-conviction sentence indication over the suicide of a patient at Casey Hospital, Berwick in 2015.
The health service sought the indication in the Victorian County Court for a WorkSafe charge of failing to ensure persons were not exposed to risk.
On 15 April, judge Gerard Mullaly indicated that if the health service pleaded guilty it would be fined no more than $160,000 and without conviction.
The mental-health patient had been found unresponsive in a visitors toilet which had a door handle previously assessed as a suicide risk, Judge Mullaly noted.
Staff were instructed to check the private toilet every 15 minutes to ensure it was left locked and not accessed by patients.
A hospital-wide audit identified ligature points on door handles, leading to them being replaced throughout the hospital’s public areas.
The handle hadn’t been replaced in the visitors toilet due to concerns that the access wouldn’t meet disability-access requirements, a prosecutor told the court.
It was replaced soon after the patient’s death.
Judge Mullaly noted the patient had been in Casey for several months on a temporary treatment order and then as a voluntary patient.
She had made 11 known suicide attempts. And in the days leading up to the event, she was anxious about her impending discharge from hospital.
Prosecutors argued in favour of a conviction due to the seriousness of the risk, the ease of remedying the risk, Monash Health being put on notice by the audit and the vulnerability of patients in its care.
Judge Mullaly said it was “highly relevant” that Monash Health had no prior workplace safety convictions given its long history operating in a “high-risk environment”.
For that reason, it was entitled to a “merciful sentence” especially given its contributions to the community in the state, nationally and internationally.
Also in mitigation was the case’s nine-year delay.
If the hospital pleaded guilty, it would also indicate Monash Health took responsibility for the incident.
Judge Mullaly considered the “compelling and heartfelt” testimonies from the “much loved” patient’s family.
“Emotions remain raw and the toll on them considerable”.
If guilty, Monash Health had a high moral culpability – being acutely aware of the patient’s vulnerability, Judge Mullaly said.
However the gravity of the breach would be still on the “lower end of the scale” because there was “little true disregard for safety”.
It was unfortunate and should not have occurred but its departure from its duty of care was not “gross” nor a “glaring disregard” from the safety of others, the judge said.
He found the “clunky” system of monitoring the toilet was “not one that satisfactorily dealt with the risks”.
The consequences – if the risks weren’t eliminated – were likely to be “catastrophic”.
Ahead of sentencing, the matter is scheduled for a plea hearing at the County Court on 6 May.
