A recent Victorian Supreme Court decision delivered the largest fine for a single offence under Victoria’s occupational health and safety laws, after a worker suffered a fatal fall while performing a non-routine task. The decision is a timely reminder that businesses cannot rely on general safety directions, routine work systems or informal supervision when workers are asked to undertake unfamiliar or one-off work.

Over recent years, all Australian jurisdictions incorporated industrial manslaughter into their WHS laws, emerging as the most serious category of offence, reflecting a shift towards stronger accountability for businesses and its officers.

We explore a recent industrial manslaughter case out of Victoria and key lessons for business when workers undertake non-routine tasks.

DPP v Risham Nominees Pty Ltd [2026] VSC 412

Background

In August 2021, Risham Nominees Pty Ltd, trading as Centenary Bakehouse (Centenary Bakehouse), was undertaking ceiling upgrades in its garlic bread bakery facility in Victoria.

The director of Risham Nominees engaged three workers to remove large insulation panels suspended in the roof space at 4 metres above the ground. The work being performed was not routine for Centenary Bakehouse.

Before the work commenced, the workers were not given any task-specific safety instructions. They were told verbally to do the job safely and not to work too close to the edge. While removing the roof panels, one of the workers fell and suffered a fatal head injury.

An investigation following the fatality identified that Centenary Bakehouse failed to:

• ensure safety control measures were in place for work at height
• have an adequate safe work method statement tailored to the task
• have appropriate fall prevention or fall arrest systems
• provide competent supervision or task-specific instructions.

The Court’s findings

Risham Nominees was charged and pleaded guilty to industrial manslaughter under section 39G(1) of the Occupational Health and Safety Act 2004 (Vic) (OHS Act).

In its plea, Risham Nominees acknowledged that all three elements under section 39G(1) were satisfied to make out the indictable offence; that is, that the company engaged in conduct that:

• fell far short of the standard of care of a reasonable body in the circumstances and was therefore negligent
• constituted a breach of its duty to eliminate or reduce risks to health and safety so far as reasonably practicable
• caused the death of another.

Justice Forbes noted the workers were not given any specific safety instructions and were instead merely told to do the job safely. Her Honour found the risk of a fall was “readily foreseeable” and it was reasonably practicable for Risham Nominees to reduce the risk of serious injury or death by using control measures, including independent scaffolding and harnesses that were available on site.

The Court found that Risham Nominees was negligent because an unfamiliar task was undertaken using an unsafe system of work and without adequate regard for worker safety.

Penalty and outcome

Risham Nominees received a conviction and was fined $3.4m, the largest ever fine for a single offence under Victoria’s WHS laws.

In reaching a decision, Justice Forbes considered:

• the nature and gravity of the offence: Her Honour found the incident was neither the product of an isolated act nor a systemic failure across all operations, as Centenary Bakehouse had safe work practices for its routine work. Rather, the failure arose because the business did not devise and implement a safe system of work for the non-routine task
• mitigating factors, including the guilty plea, evidence that Risham Nominees was a corporate citizen of good character and evidence that the director had taken steps to address occupational health and safety concerns following the WorkSafe investigation.

Justice Forbes was not persuaded that an Adverse Publicity Order (APO) under section 135 of the OHS Act, as sought by the DPP, was appropriate. Her Honour found this case to be more analogous to general promotional publicity rather than a targeted public statement.

What this means for businesses and officers

The decision highlights that a business may have safe systems for its ordinary operations but still be exposed where those systems do not capture or cannot extend to non-routine work. For officers and leaders, the case underscores the need to ensure safety processes can adapt for ad hoc, maintenance, facilities and project-based work, particularly where the work involves height, plant, electrical risks, confined spaces or other high-risk activities.

General instructions to “be careful” or “do the job safely” are unlikely to be sufficient where a task creates a readily foreseeable risk of serious injury or death. Businesses must be able to demonstrate that risks have been identified, appropriate controls have been selected and implemented, and workers have received clear instructions, been consulted and have competent supervision before the work begins.

Practical steps for businesses

Businesses should consider whether their WHS systems require:

• a task-specific risk assessment and worker consultation before non-routine, maintenance or one-off work begins
• confirmation that appropriate controls are in place before work at height or other high-risk work is performed
• safe work method statements or procedures that reflect the actual task, location and method of work
• competent supervision by someone who understands the relevant risk and controls
• clear escalation processes where workers are asked to perform tasks outside ordinary operations
• officer-level reporting on serious WHS risks, including non-routine work and contractor activities
• post-incident review processes that test whether safety systems operated as intended.

The Gadens Workplace Advisory and Disputes team can assist businesses to review WHS management systems, officer due diligence frameworks, safety documentation and risk controls for non-routine and high-risk work. Contact our experts below.