Monash Health has pleaded guilty to a workplace safety charge over the suicide of a mental-health patient at Casey Hospital, Berwick in 2015.
In pleading on 6 May, the health service accepted an earlier sentence indication in the Victorian County Court of a non-conviction and a fine no more than $160,000.
Prosecutor Duncan Chisholm told the court that Rebecca Victoria Poke was found unresponsive on 31 August 2015 in a visitors toilet, which had a door handle type previously assessed as a suicide risk.
Staff had been instructed to check the private toilet every 15 minutes to ensure it was left locked and not accessed by patients.
In an audit in April 2015, the visitors toilet door handle was identified as a ligature risk.
However, unlike every other door handle in the ward, it hadn’t been replaced, the court heard.
Monash Health should have either removed the handle, replaced it with a ligature-proof pull handle or replaced it with a ligature-proof lock set, Mr Chisholm said.
It was removed shortly after the incident.
Ms Poke had been admitted into Casey’s acute mental health ward as a high risk of suicide.
During her stay over several months, she had made 11 suicide attempts.
She was taken off a compulsory treatment order and was due to be released to visit family and friends shortly before the incident.
Her bereaved father, mother, brother, sister and husband submitted victim impact statements to the court.
Ms Poke’s father Shane Middleton said he was forced to take a long time off work to deal with her senseless and unnecessary loss, and felt like he was in a living nightmare since she died.
He feared for her twin sister and felt his life was a debt-burdened “disaster” after Ms Poke’s death, which led to the breakdown of his marriage, he said.
“I feel like I am in a continual battle for survival,” Mr Middleton said in a statement read to the court.
Ms Poke’s brother Cameron Middleton said his anger was initially misdirected at his sister.
He had since become angry at the hospital and relived his sister’s death over and over, he said.
Mental-health risk assessment expert Professor Matthew Large later reported there was no reasonable explanation for keeping the door handle which posed a “significant risk” to patients, Mr Chisholm said.
His report stated that the need for ligature proof door handles was well known in the industry, been available for decades and were “not expensive”, the court heard.
According to defence submissions, Monash Health had eliminated many ligature point risks but not that “specific risk”.
“Insofar as they was an error (which is easy to point out in hindsight…) it was a human one in under-estimating the capacity of a determined patient to effectively ‘stake out’ the door and wait for it to be left unlocked and to sneak in without being observed by the person(s) at the Nurses Station.”
In an earlier hospital audit, the door handle was assessed as “low” risk due to being in a low dependency unit and a high-visibility corridor.
The handle couldn’t be removed because it was the only disabled bathroom on the ward, an audit stated.
Last month, judge Gerard Mullaly indicated that if Monash Health pleaded guilty, it would be fined no more than $160,000 and without conviction.
He had said it was “highly relevant” that the health service had no prior convictions given its long history operating in a “high-risk environment”.
The maximum penalty applicable is $1,328,490.
Monash Health will appear for sentencing at the Victorian County Court on 16 May.
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