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Non-conviction indicated for Monash Health

Vaseline 2 months ago

By Cam Lucadou-Wells

Monash Health has been awarded a non-conviction judgment over the suicide of a patient at Casey Hospital, Berwick in 2015.

The health department applied to the Victorian County Court for a charge against WorkSafe for failing to ensure individuals were not exposed to risk.

On April 15, Judge Gerard Mullaly indicated that if Healthcare were to plead guilty, she would be fined not more than $160,000, with no conviction.

The psychiatric patient was found unconscious in a visitors’ toilet with 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 locked and inaccessible to patients.

A hospital-wide audit identified ligature points on door handles, prompting their replacement in public areas of the hospital.

The visitor toilet handle had not been replaced because there were concerns it would not meet disabled access requirements, a prosecutor told the court.

It was replaced shortly after the patient’s death.

Judge Mullaly noted that the patient had been in Casey for several months for temporary treatment and then as a voluntary patient.

She had made 11 suicide attempts. And in the days leading up to the event, she worried about her impending release from the hospital.

Prosecutors argued for a conviction based on the severity of the risk, the ease with which the risk could be remedied, the fact that Monash Health was notified by the audit and the vulnerability of the patients in its care.

Judge Mullaly said it was “highly relevant” that Monash Health had no previous workplace safety convictions given its long history of operating in a “risky environment”.

For this reason, the country was entitled to “merciful punishment”, especially considering its contributions to the community in the state, nationally and internationally.

What also led to mitigating circumstances was the nine-year delay in the case.

If the hospital pleaded guilty, it would also mean Monash Health took responsibility for the incident.

Judge Mullaly considered the “compelling and heartfelt” testimony of the family of the “much-loved” patient.

“Emotions remain raw and their toll is significant.”

If guilty, Monash Health had a high moral culpability – because it was acutely aware of the patient’s vulnerability, Judge Mullaly said.

However, the severity of the breach is still said to be at the “lower end of the scale” as there was “little real disregard for safety”.

It was unfortunate and should not have happened, but the departure from his duty of care was not “gross” nor a “flaunting disregard” for the safety of others, the judge said.

He felt the ‘clunky’ system of toilet monitoring was ‘not a system that dealt with the risks satisfactorily’.

The consequences – if the risks were not eliminated – would likely be “catastrophic”.

Prior to sentencing, the case will be heard at the County Court on May 6.