Sufficient support for the mental health of returned travellers detained in COVID-19 hotel quarantine was not in place when a former Melbourne man took his own life.
Cameron Plant died in his hotel room during a period in hotel quarantine in April 2020, an inquest into his death was told on Tuesday.
He was granted a place on a repatriation flight from Dubai to Melbourne on April 3.
Mr Plant, 57, lived abroad for a decade but decided to return to Melbourne after the start of the COVID-19 pandemic.
He worked in commercial radio in Dubai but after suddenly losing his job, transferred to the events industry.
Work became unstable and Mr Plant separated from his wife of four years.
Until April 10 Mr Plant spoke daily to Department of Health officials who did health assessments.
Telephone records show he made multiple calls during his time in the hotel room and had conversations with friends on WhatsApp.
His cousin, who he planned to live with after leaving quarantine, told investigators Mr Plant seemed in good spirits considering what he had been through with the breakdown of his marriage.
Nursing staff last spoke to him at about 4pm on April 10 and said he hadn't advised of any welfare concerns.
About midday on April 11 hotel quarantine staff were told Mr Plant wasn't answering his phone and had not collected meals left outside his door.
Security and nursing staff entered inside and found him unresponsive.
State Coroner John Cain referred to findings from Jennifer Coate's report into hotel quarantine, noting the conception and implementation of the program within 36 hours placed extraordinary strain on Victorian resources.
"This lack of planning was most a unsatisfactory situation from which to develop such a complex, high-risk program," he said.
Much had been done to improve arrangements to assess and support return travellers since Mr Plant's death, Judge Cain said.
"I'm not in a position to say whether, had those arrangements been in place at the time of Mr Plant's entry into hotel quarantine, that his death would have been prevented," he said.
But he believes the system later introduced would have provided the best opportunity to support Mr Plant and provide him with timely assistance.
Recommendations made by Ms Coate and in a separate inquiry by Safer Care Victoria were appropriately made, he said.
WorkSafe also investigated Mr Plant's death and no charges have been laid.
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