In January 2018 a risk management officer at Victoria's Coroners Court flagged such serious concerns with morale, bullying and stress that he believed there was a grave risk of a colleague taking their own life.
Tragically he was right and in September that year senior lawyer Jessica Wilby suicided.
She had been weighed down by the pressure of backfilling the senior legal counsel role while maintaining her full caseload as principle in-house solicitor.
Ms Wilby had been in tears at work because of the pressure and after a conversation with an acting chief executive in which she was told "you hate me - you need to tell your team to like me".
Court Services Victoria, which oversees the Coroners Court of Victoria, has pleaded guilty to failing to conduct any adequate process to identify risk or adequate assessment of the risk to psychosocial health of employees at the court between 2015 and 2018.
A prosecutor broke down and couldn't finish reading an emotional statement written by Ms Wilby's sister Caroline, who wrongly believed she failed in trying to stand by her sibling.
Senior prosecutor Jason Gullaci took over to finish describing the unfounded guilt Caroline Wilby felt that she was alive and Jess was not, before Magistrate Glenn Walsh stammered emotionally through condolences for the young lawyer's family.
The magistrate - brought from NSW as an impartial adjudicator - rushed from court, adjourning the hearing briefly, after the emotional statement.
Bullying, inappropriate behaviour and low morale were identified in a staff survey in December 2015, prompting a risk management plan and mandatory training programs.
A risk officer was employed in 2017 but they found complaints about inappropriate behaviour kept coming.
Issues ranged from bullying to favouritism, cronyism, verbal abuse, derogatory comments and perceived threats about future progression.
Multiple staff took leave, expressing feelings of anxiety, fear, humiliation and symptoms of post traumatic stress disorder.
The risk officer began to draft risk registers, but by January 2018 he was forced to suspend that work because of staffing issues, including senior staff taking unplanned leave.
"I don't believe there is a stable and positive environment for us to discuss the risks," he said, according to Mr Gullaci during a pre-sentence hearing.
In February that year a senior staff member met with the risk officer, expressing grave concerns for colleagues as a result of working with the Coroners Court.
The risk officer in turn raised his own concerns with higher ups that there was a "strong risk of suicide at the Coroners Court".
A former staffer who once dreamed of being a coroner told the hearing she is so deeply affected by her time there she was forced to leave the profession in June this year to deal with her own mental health.
She's struggling with the disappointment of a longed-for career path being gone, while questioning if she'll be able to re-enter the profession.
Another former employee noted how closely their careers were tied to their workplace - there wasn't another coroners court down the road they could go to.
Patrick Doyle SC, representing Court Services Victoria, acknowledged the experiences of those people who were harmed and who continue to suffer.
He said as well as being remorseful for its actions and the tragic death of Ms Wilby, CSV had accepted that more was wrong at the Coroners Court than they were even charged over.
"I've never had instructions like that in my life - to acknowledge greater wrongdoing than is reflected in the charge," he said.
A genuine and committed effort has been underway to improve risk management since 2018, he said.
Chief people officer Jewil Fulton told the court since her appointment as human resource lead three years ago, nine critical and credible risk areas were identified as common across all court jurisdictions in Victoria, with vicarious trauma, workload stress and sexual harassment being addressed as priorities.
CSV faces a maximum fine of nearly $380,000.
Mr Walsh will hand down his sentence at a later date.
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