Melbourne Health has pleaded guilty to health and safety violations more than seven years after a patient took his own life at a publicly run psychiatric unit.
Mental health patient Peter Nolan, 75, died by suicide at the Melbourne Health-operated Broadmeadows unit in September 2013.
Melbourne Health faces a maximum penalty of nearly $1.3 million after pleading guilty in Victoria's County Court to failing to ensure people other than employees were not exposed to health and safety risks.
One of Mr Nolan's six surviving children, Phillip, cried as he told Judge Amanda Fox on Wednesday it was impossible to do his father justice.
"(I am) sorry I was not there in his darkest hour when he entered the valley of death," he said.
"It saddens me that I can no longer share a beer with him in his favourite places.
"I miss Dad and I wish he was still alive."
Mr Nolan was admitted to the Broadmeadows Aged Persons Mental Health Unit, initially as an involuntary patient.
He was considered a high suicide risk and required 15-minute observations.
Less than two days later, Mr Nolan was found dead.
One of his children alerted WorkSafe to the death in July 2014.
Nearly three years later, the family again contacted WorkSafe and urged it to reopen its investigation following an inquest.
Charges were not laid until June 2019.
Mr Nolan's widow, Marie, said she was not the type to hold a grudge and would "turn the other cheek" to Melbourne Health.
"I thought that Peter would be safe in the hospital," she said in a statement.
"Sadly, I was wrong."
The court was told it was the first prosecution in Victoria for a suicide in a mental health facility.
In this case, a patient transfer sheet was being used as a curtain, which was not in line with Melbourne Health's ligature policy.
On behalf of the Melbourne Health division that ran the facility, operations director Peter Kelly apologised for the loss and and hurt suffered by Mr Nolan's family.
"Melbourne Health is profoundly sorry for your irreplaceable loss," he said in part of an affidavit read to court.
Acting for Melbourne Health, barrister Patrick Barry said changes had since been made, including to better prevent possible self-harm attempts.
There had been a system in place to mitigate the risk but it was not followed in this instance, he conceded.
The barrister described Mr Nolan's death as an "utterly tragic and preventable incident".
"This is not a case of an accused that had a cavalier disregard for safety," Mr Barry said.
"Melbourne Health accepts that it can always do better."
Judge Fox will hand down her sentence in April.
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