Melbourne Health convicted and fined $340,000 in patient suicide case

A major public healthcare provider has been convicted and fined $340,000 for breaching workplace health and safety laws in failing to identify and control a suicide risk to a patient. Victorian County Court Judge Amanda Fox said she would have fined Melbourne Health $520,000 if it had not pleaded guilty to the breach.

Melbourne Health's undertakings included operating a mental health impatient facility in Broadmeadows, where aged persons with acute mental illnesses were assessed and treated, and often involuntarily admitted under the State Mental Health Act 2014.

In September 2013, a 75-year-old man admitted to the facility, and identified as being at a high risk of suicide, hanged himself in his room using a slide sheet designed for manually handling patients.

At the June 2017 coronial inquest into the man's death the Victorian Coroner, Peter White, found that: 

  • at least two days before the incident, a facility staff member attached the slide sheet to the window in the man's room to replace a curtain that had fallen down; 
  • there was no evidence to suggest that any risk analysis was done regarding the the use of such a sheet as a curtain in the room of a person who had been admitted because he was at risk of suicide;
  • no steps had been taken to replace the curtain, or to notify appropriate staff of the need to replace it; 
  • at the relevant time, the 19-bed facility was being supervised by only two staff members, who were both "extremely busy with waking patients"; and
  • it was unlikely that the workers checked on the 75-year-old man every 15 minutes, as required. 

In June 2019, WorkSafe Victoria charged Melbourne Health with contravening section 23 ("Duties of employers to other persons") of the State Occupational Health and Safety Act 2004. WorkSafe alleged the healthcare provider failed to ensure, so far as was reasonably practicable, that the patient was not exposed to risks to his health or safety arising from the conduct of its undertaking.

In the County Court, Melbourne Health acknowledged, through its guilty plea, that it had been reasonably practicable for it to identify the risk of the slide sheet being used as a ligature for hanging, resulting in serious injury or death. It accepted it had been reasonably practicable to ensure the slide sheet was removed and not available to be used for hanging.

Judge Fox noted Melbourne Health pleaded guilty at the earliest opportunity, was an otherwise good corporate citizen, responded to the incident with workplace improvements, apologised to the deceased man's family, and demonstrated remorse. Source: OHSAlert

To check for any Victorian prosecutions before the next edition, go to WorkSafe Victoria's Prosecution Result Summaries and Enforceable Undertakings webpage. 

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