Melbourne Health has been fined $340,000 for health and safety breaches more than seven years after a patient took his own life at a psychiatric unit.
Peter Nolan, 75, died by suicide at the Melbourne Health-operated Broadmeadows unit in September 2013.
Victoria's second-largest public health service was convicted in the County Court on Friday and fined for failing to ensure people other than employees were not exposed to health and safety risks.
The breach centred on the use of a slide sheet as a makeshift curtain in Mr Nolan's room. This was not in line with Melbourne Health's ligature policy.
Judge Amanda Fox said it was a clearly visible and an obvious risk that could have been easily and cheaply remedied.
"Peter Nolan, at a place where he should have been safer, was able to take his own life," the judge said.
She also noted no instruction had been given to staff at the unit about the use of makeshift curtains before Mr Nolan's death.
Melbourne Health faced a maximum possible fine of nearly $1.3 million.
Judge Fox stressed the penalty imposed was not a reflection on the value of Mr Nolan's life, and that nothing the court did or said could heal his family's pain and suffering.
The much-loved father of nine and grandfather of 13 was a "warm, generous, outgoing and likeable" man.
He was admitted to the Broadmeadows Aged Persons Mental Health Unit after trying to take his own life.
Initially an involuntary inpatient, he was considered a high suicide risk and on 15-minute observations when he died less than two days later.
The psychiatric unit was designed to be as home-like as possible, which is why it had curtains.
Since Mr Nolan's death, Melbourne Health has made changes to better prevent potential self-harm.
Curtains have been replaced with Venetian blinds enclosed within the glass windows and operated remotely. Slide sheets are kept under lock and key.
Melbourne Health was not charged until June 2019.
WorkSafe Victoria was alerted to Mr Nolan's death by one of his children in 2014.
It re-opened its investigation after being contacted again by the family following 2017 inquest findings.
It's the first prosecution in Victoria for a suicide at a mental health facility.
Melbourne Health has apologised in court for the loss and hurt suffered by Mr Nolan's family.
It has also agreed to repay the funeral cost and to four different compensation orders relating to family members.
Judge Fox said this was not a case of deliberately cut corners, a cavalier attitude to safety or cost cutting.
Rather, the procedures and systems in place at the time were not followed.
Mr Nolan's widow, Marie, previously 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 an earlier statement to the court.
"Sadly, I was wrong."
One of Mr Nolan's six surviving children, Phillip, said he was "sorry I was not there in his darkest hour when he entered the valley of death".
"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."
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