National guidelines on restraining aggressive hospital patients are confusing and should be reviewed, a coroner says.
Hospitals needed consistent rules on how to restrain patients, Peter White said on Wednesday in giving his finding on the deaths of two Melbourne men in psychiatric units.
No patient should have pressure applied to their trunk while being restrained, he said.
Mr White found that Justin Fraser and Adam White died in 2007 as a result of the pressure applied to their trunks as they were wrestled to the ground at units run by Dandenong Hospital and Frankston Hospital.
He White said the men had heart conditions and the pressure applied to their abdomens led to their "avoidable" deaths.
He recommended that the Office of the Chief Psychiatrist issue a "practice guideline" on restraints.
He rejected Peninsula Health's assertion that Mr Fraser died as a result of excited delirium at the Frankston Hospital's psychiatric unit.
Mr White also called for qualified medical staff to be present and monitor a patient while restrained.
He said the review of the Victorian Mental Health Act to consider regulations for the safe physical restraint of patients.
Mrs Sharon Fraser and Mr White's sister, Tracey Downward, called for any change to clauses on restraints be named in the honour of the dead men.
Mrs Fraser said she intended to pursue Peninsula Health through the courts as a result of the findings.
Ms Downward said her family had placed their trust in Dandenong Hospital to care for Mr White, 31, who had alcohol and substance abuse problems and a schizophrenia condition.
"It is good to hear today that the hospital was at fault, that the coroner has understood that, and that some changes can come of it," Ms Downward said.
Peninsula Health's clinical director of mental health, Dr Sean Jespersen, said the health network was saddened by Mr Fraser's death.
"We participated fully in the inquest and will review the findings, respond to recommendations and make any appropriate further improvements," Dr Jespersen said.
"We note the important balance between managing aggressive patients and maintaining a safe environment for patients and staff.
Mr White said both hospitals had made improvements as a result of the deaths.