Victoria's overcrowded maximum security psychiatric hospital could be substantially expanded to cope with the number of inmates who need to be transferred from Victoria's prisons.
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An independent review into patient safety sparked by a cluster of potentially preventable baby deaths at a Bacchus Marsh Hospital has also found the bed-strapped Thomas Embling Hospital, the only hospital in the state that treats people found not guilty because of mental impairment, urgently needed resources.
In April this year, Easton Woodhead, 21, the ex Melbourne Grammar student who stabbed homeless man Wayne 'Mouse' Perry to death in 2014, was reported to have spent at least five months in prison waiting for a bed to become available at Thomas Embling.
In August, staff at the hospital went on strike to demand greater protection after hundreds of attacks from violent patients in recent months raised safety fears.
In its annual report, Forensicare, which manages Thomas Embling, said the increasing demands on its services were of "extreme concern".
Apart from Thomas Embling, the service runs mental health programs at several prisons including the Dame Phyllis Frost Centre, and runs visiting services to others.
From next year, it will also run mental health services at Port Phillip Prison, and will operate the 75-bed mental health unit in the new Ravenhall Correctional Centre. However, pressures are acute - particularly in the remand system, with an average of 10 men or more awaiting transfer to Thomas Embling Hospital from the Melbourne Assessment Prison.
Clinical director Maurice Magner said it had "sadly become the norm during the year that at least 10 prisoners wait to be transferred for compulsory treatment ... on any day of the week".
"On average these certified prisoners may wait a month before a bed becomes available at Thomas Embling Hospital. It takes little imagination to understand the conditions under which these prisoners are detained: floridly psychotic with no psychiatric treatment and detained in prison cells."
The new plan sets a clear timeline to increase the number of beds and to "address other needs including those of adolescent and high-security patients."
Dr Duckett said forensic mental health care emerged as a particularly vexing problem during the review, which interviewed about 500 people.
"People aren't getting into Thomas Embling who ought to be getting into Thomas Embling," Dr Duckett said.
Health Minister Jill Hennessy will on Friday reveal plans to develop a master plan of options for Thomas Embling.
The government will also reveal plans to increase the mental health workforce by funding an additional 130 mental health staff.
Mental Health Minister Martin Foley said one in four people entering prison were taking medication for a mental health disorder.
Tom Dalton, chief executive of Forensicare, which manages Thomas Embling, said the reforms would help to deliver "first-class mental health care".
