Former radio host Mel Greig has made a tearful apology to the family of nurse Jacintha Saldanha, who took her own life following an Australian radio station hoax.
In a statement to the inquest into the nurse's death, a weeping Ms Greig placed the blame directly on the radio station, and a commercial radio culture of humiliation.
She addressed her statement directly to Ms Saldanha's husband and teenage son and daughter in the court, saying "First to Jacintha's family: I am so sorry for your loss. I have wanted to say that to you for so long.
"I wish I'd tried harder to stop the prank call from airing. There is a lot to learn from this tragic event.
"I believe that hospitals and media organisations should look into their procedures and policies to ensure a tragedy like this never happens again.
"To fellow announcers and DJs I urge you to speak up if you don't feel comfortable and to consider the feelings of others when trying to make a joke.
"The joke should always be on us the DJs."
Ms Saldanha, 46, the night nurse at King Edward VII Hospital in London, killed herself on December 6 2012, two days after taking a call from 2Day FM radio hosts Michael Christian and Greig, who were impersonating the Queen and Prince Charles.
She handed the call to another nurse, who revealed confidential details about the treatment of the Duchess of Cambridge, who was at the hospital suffering from severe morning sickness.
"I don't know how to face the bosses tomorrow," Ms Saldanha told a colleague.
A coroner declined to place the blame for her death on either the radio station or the hospital, as she reached a finding of death by suicide.
At the time of Ms Saldanha's death the hoax call – as well as a dispute with a junior colleague who had accused her of bullying – were "pressing on her mind", the coroner Dr Fiona Wilcox found.
But her actions came as a complete surprise to her family, friends and colleagues.
"The (death) was not reasonably foreseeable, as the support given to Ms Saldanha in between the hoax call and her death was reasonable and appropriate," Dr Wilcox said.
Those bosses were not to blame for her death, a coroner found on Friday – despite the hospital's chief executive admitting they could have done more to help her.
They were unaware of what she was going through, thinking she was a tough individual who would deal with the pressure, and could not have predicted her suicide.
Outside the court British MP Keith Vaz, who has been helping the family, hinted that they were looking into possible legal action against the hospital and against Southern Cross Radio.
The calls "which were the cause of such mirth in Australia. …deprived Ben of his wife, and Lisha and Junal of their beloved mother," Mr Vaz said. "These despicable and cruel actions, this hoax has changed their lives forever.
"The family of course accept the verdict of the coroner's court."
Junal, 18, also made a short statement on behalf of the family thanking people in Britain and around the world "who comforted and supported us".
"My dad and sister and myself miss our beloved mum every day and will do so for the rest of our lives," he said.
In a statement King Edward VII Hospital welcomed the coroner's finding that the hospital "did everything it reasonably could to support Jacintha following the hoax call."
John Lofthouse, who was chief executive of King Edward VII Hospital at the time, admitted to the inquest on Friday that Ms Saldanha had not received enough support after the hoax call.
She was clearly embarrassed and upset, he said, but the hospital was providing support and reassurance, and he had believed she was a "reasonably robust and resilient individual and not (someone) toward whom our reaction needed to be over the top".
"The hindsight we now have tells us that in Jacintha's case certainly more support should have been given, but we did not have the benefit of that hindsight."
There was never going to be any disciplinary process for the nurses, he said – the hospital's approach was that "she was to be provided with reassurance".
However in an email sent to a senior nurse in the middle of the night, hours before she died, Ms Saldanha said she was "still very upset" about the phone call.
"I feel I am to blame after all it was my fault. I don't know how to face the bosses tomorrow. I feel so ashamed of myself."
Mr Lofthouse said he only found out about the email later.
"If any of those on the management team had had any inkling of any fragility on the part of Jacintha's emotional state we would of course have handled it differently," he said. "If we had any idea of the possibility she might take her life we would have reacted in a completely different way, we would have put our arms around her, literally and metaphorically.
"But no alarm bells rang for any members of the management team she contacted, any of the staff in contact with her over the 12-hour shift, and of the people who lived with her, any of her friends."
For much of the night before her death Ms Saldanha had been searching the internet for news stories about the hoax call, and then for information on suicide prevention – and then blood circulation.
Those seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or Suicide Call Back Service 1300 659 467.
