Canberra Hospital says it regrets four patients died by suicide in its mental health ward in 2015 and 2016, offering condolences to the affected families.
It has disputed claims by the coroner it did not act fast enough to remove safety hazards in the hospital's adult mental health unit.
Executive director of mental health services, Karen Grace, said the unit was now safer than most similar facilities across the country.
The hospital began work to remove hazardous ligature points in 2018, with the work not completed until 2019.
But coroner Margaret Hunter had suggested it was only the threat of losing accreditation that prompted the hospital to act on the ligature points.
"I think it's not fair to say there was delay in taking action," Ms Grace said.
"It has taken some time because of the complex logistics behind it. This was a really, really difficult and complex piece of work that needed to be planned and executed really carefully."
Ms Hunter handed down her findings into the four deaths 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 four patients were Nicola Fisher, 49, Anthony Bearham, 26, and a 59-year-old woman and 56-year-old man who cannot be named.
Ms Grace said the hospital would act on the coroner's seven recommendations, with work on some of them already under way.
They included the need for more CCTV and a review into the policy around dangerous items being brought in by patients.
Ms Grace conceded the service had struggled to meet ever-increasing demand.
"You can't just create mental health beds overnight," she said.
"They have specific requirements and you need time in order to increase the bed base for a mental health service to standard. We have at different times struggled to meet the demand that exists in the community and we have proactively attempted to plan and manage for that. And that is true now as it was five years ago. There are times where we can't predict surges in demand to our service."
But Ms Grace said the hospital was doing what it could to expand its services, including through the opening of a new low-dependency unit.
It was also working towards getting more high-dependency beds.
"I do absolutely feel for all four families at this time," she said.
"We did take these situations seriously at the time, we have taken them seriously since and we will continue to do so for the sake of those people that come after them."
Opposition health spokeswoman Giulia Jones said chronic understaffing at Canberra Hospital needed to be addressed immediately.
"While the report indicates some improvements have been made since these incidents, serious concerns remain," she said.
"With promised additional funding for mental health from the Labor-Greens government in the budget, I hope this money will be better spent to address these issues and a long-term strategy to fix the understaffing."
Ms Jones also raised concerns about the long coronial process
"For the grieving families, waiting up to six years for the completion of the inquest process is far too long and highlights the under-resourcing of the coronial court," she said.
- Lifeline 13 11 14
- Beyond Blue 1300 224 636
Our journalists work hard to provide local, up-to-date news to the community. This is how you can continue to access our trusted content: