A coronial inquest in 2020 found that failures on the part of Bendigo Health directly contributed to the death by suicide of a 46-year-old woman.

She was being treated at the Alexander Bayne Centre, which housed Bendigo Health's inpatient mental health services at that time.

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Coroner Simon McGregor recommended Bendigo Health amend its protocol for searching patients and visitors in psychiatry inpatient areas.

He said that when patients were found with a prohibited item all reasonable efforts should be made to identify how the patient got the item and steps taken to prevent future access.

The coroner found that the woman, a mother of four, ultimately ended her life with an item she had been discovered with in the days leading up to the incident.

She had been comforted by a staff member at that time and had willingly surrendered the item.

The coroner found that a formal risk assessment was required following the significant deterioration in her condition on the morning of 27 August 2016, and that Bendigo Health staff "failed to do this".

He said that in the days and weeks before her death, the woman had expressed suicidal thoughts.

The inquest findings determined that there were insufficient staff to carry out the hourly observation on the woman, and this failure directly contributed to her death.

"If staff had discovered her twenty minutes earlier it is certain that her chances of survival would have been distinctly higher," Mr McGregor said.

"Failing to ensure that this observation occurred was a material departure from the standards to be expected of an acute inpatient psychiatric unit, and there is sufficient evidence for me to conclude that it directly contributed to [the woman's] death," Mr McGregor said.

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He said multiple staff had underestimated the woman's suicide risk, although this did not appear to have had a direct impact on the treatment she received.

Mr McGregor said the organisation had already made changes in the wake of the woman's death.

"I commend the work they have undertaken to protect their patients and prevent deaths such as [the woman's] from occurring in the future, and I am confident that this work will continue," he said.

Bendigo Health is expected to appear at the Bendigo Magistrates Court on August 24 in relation to the charges laid by the Victorian Workcover Authority.

If you need help you can contact Lifeline on 13 11 14 or the Suicide Call Back Service on 1300 659 467.

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