Monash Health has escaped conviction after admitting it failed to ensure one of its most vulnerable patients was not exposed to risk of harm.
Rebecca Victoria Poke died by suicide at Casey Hospital in Berwick in September 2015 after being voluntarily admitted to the hospital’s mental health inpatient unit.
The hospital audited the suicide risk to patients in the unit in April 2015 and flagged a visitor’s bathroom as a potential concern but did not eliminate the risk.
Nurses found Ms Poke unresponsive in that bathroom on August 31 and she died in hospital two days later.
In sentencing Monash Health to a $160,000 fine, Victorian County Court Judge Gerard Mullaly said while the hospital failed in its duty of care, it did not have glaring disregard for patient safety.
The hospital attended to the general risk of self-harm and made appropriate changes to bathrooms that were more readily accessible to patients, Judge Mullaly said.
The bathroom in question was usually locked and could only be accessed by a supervisor’s key but it was inexplicably open for Ms Poke, the judge said.
He said the circumstances were tragic but the failure on Monash Health’s part was at the lower end.
The judge also pointed to the health service’s guilty plea and its otherwise good corporate character as it had no prior convictions.
“That is a matter of considerable weight given the history of this large organisation,” Judge Mulally said.
The judge also noted the victim impact statements made by Ms Poke’s family, who remembered her as a much-loved woman who was dearly missed.
Judge Mulally said the $160,000 fine without conviction was not a reflection of Ms Poke’s life.
“Her life was quite simply invaluable to her and her family,” he said.
After the sentence was handed down, WorkSafe executive director Narelle Beer said the tragic incident could have been avoided.
“Ways to control the risk of deaths by suicide in mental health units have been well understood in the healthcare industry for many years,” Dr Beer said.
“WorkSafe will not hesitate to take strong enforcement action when duty holders are not doing everything they can to protect those in their care, including from intentional self-harm.”
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