Coroner Olivia McTaggart found there were staff and bedding shortages in the early hours of July 10, 2016, when Joseph Aaron Lattimer was brought to the hospital by ambulance to prevent him from taking his own life at his Mornington home.

Mr Lattimer was triaged by a nurse upon arrival, but left alone in the waiting room for 46 minutes to wait for admission into the emergency department.

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Ms McTaggart said no Psychiatric Emergency Nurse was on duty at the time and there was no support person or other staff member available who could sit with him to ensure his safety and provide reassurance.

The nurse who had first seen Mr Lattimer found him in the cubicle going into cardiac arrest. He was placed on life support, but removed from that 11 days later.

The coronial inquest heard Mr Lattimer had a history of drug and alcohol abuse and struggles with anxiety and depression.

His mental issues worsened when he suffered an acquired brain injury in 2013.

He confided in his general practitioner that year he had suicidal thoughts, but these were not deemed to be high risk.

The court heard Mr Lattimer in the years since his brain injury sought on numerous occasions to limit his substance abuse and seek help for his depression and suicidal ideation.

The court heard a passion for sailing and the purchase of a yacht had made a positive change in Mr Lattimer's mental health and reduced his addictive behaviours in the six weeks before his death.

Hours before the incident, he discussed plans with his father for a yachting adventure.

Ms McTaggart in her findings did not criticise the staff working in the emergency department on the night.

"The issues affecting Mr Lattimer's situation were caused by insufficient staff to attend to him and insufficient, appropriate space to accommodate him," she said.

Ms McTaggart recommended the government assessed the requirement for Psychiatric Emergency Nurses at the hospital and recruit sufficient numbers to enable proper triage, assessment and treatment of emergency department mental health presentations.

A state government spokesperson said the Psychiatric Emergency Nurse service at the hospital has an established 5.79 full-time equivalent positions, with agency and casual staff utilised to fill vacancies where possible.