The Canberra Hospital failed four patients who died by suicide while in its care in 2015 and 2016, an inquest has found.
The patients were admitted to the hospital's mental health units because of the risk they would take their own lives and all died within the space of two years, prompting a coronial inquest.
Coroner Margaret Hunter handed down her findings on Thursday, highlighting inadequacies in staffing, insufficient training and insufficient attention to practice and procedure.
It was common for nurses to work double shifts, including at the time of these deaths, she said.
The patients were found too late to have had access to dangerous items, and the hospital was slow to respond to risks in the units, the inquest found.
But Ms Hunter also commended the hospital for improvements it had already made, noting that no one had died by suicide there in the years since.
She said that was the "lasting legacy" that had been forged by the four patients' deaths.
The ACT Minister for Mental Health Emma Davidson said after the findings that a lot of work had already been done at the hospital, especially addressing the risks in the units.
The four patients were Nicola Fisher, 49, Anthony Bearham, 26, and a 59-year-old woman and 56-year-old man who cannot be named.
Outside court, Ms Fisher's sister Melanie Fisher said the hospital had failed them but blaming terribly overworked staff at the hospital was "like blaming the captain of the Hindenburg for the fire that was caused by the fact that they filled the balloon with hydrogen".
She pointed to the "wildly inadequate" funding of mental health services.
"We don't need more reviews, we don't need more royal commissions, we don't need more reports ... we know what needs to be done and it's just a matter of priorities," she said.
She said turning people away from hospital who needed help with their mental health was the equivalent of a woman turning up in labour to the hospital to deliver her baby and being told, 'we're terribly sorry we're full, you're just going to have to go home and do this on your own'."
Mother Sueellen Tate, whose son Mr Bearham's death was also being examined, wanted to see positive come from a negative situation
She said changes at the mental health unit were making it a safer place to house people with mental illness.
"When a patient goes into [the unit] it's because they're not in a right frame of mind and they need care," she said, adding they needed to be separated from triggers like social media and phones.
Ms Tate also said if a patient was allowed out on day leave, then processes were needed to check the patient for dangerous goods when they come back.
"Safety has to be paramount for everyone," she said.
The coroner apologised to the families for the long waits to hear the findings of the inquest into their loved ones' deaths.
Ros Williams from the Alliance for Coronial Reform said lengthy delays were always a huge concern and the group has been campaigning for a dedicated coroner.
"Six years is too long to wait for recommendations to be handed down for those families, it's a very stressful and traumatic time," she said.
"And even though I don't think many families move on, it makes that whole grieving process extremely difficult."
The coroner made seven recommendations, including more CCTV, and a review into the policy around dangerous items being brought in by patients.
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