Coronial
VICother

Finding into death of Stuart Hill

Deceased

Stuart Andrew Hill

Demographics

40y, male

Coroner

Coroner Peter White

Date of death

2008-01-22

Finding date

2011-10-05

Cause of death

drug overdose (propofol)

AI-generated summary

Stuart Hill, a 40-year-old anaesthetic and recovery nurse at the Alfred Hospital with a history of anxiety and depression, died by intentional drug overdose using propofol and rocuronium obtained from his workplace. Following a relationship argument on 21 January 2008, he left stating suicidal intent. The next morning his vehicle was found near his residence with him deceased inside. The coroner found he deliberately ended his life while suffering from depressive illness. Key clinical lessons include: recognition of suicide risk in healthcare workers with mental health conditions, importance of secure medication storage and auditing of controlled substances, and the need for workplace support systems. The coroner recommended emphasised auditing of unused anaesthetics to prevent unauthorised access.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

anaesthesiapsychiatry

Drugs involved

propofolrocuronium

Contributing factors

  • history of anxiety and depression
  • suicidal ideation following relationship conflict
  • access to anaesthetic drugs at workplace
  • inadequate security of medication storage

Coroner's recommendations

  1. Details of this case be provided to those responsible for the management of unused anaesthetics at the Alfred Hospital with a view to giving emphasis to the need for ongoing careful auditing of unused supplies
Full text

FORM 38 Rule 60(2)

FINDING INTO DEATH WITHOUT INQUEST

Section 67 of the Coroners Act 2008 Court reference: 333/08 In the Coroners Court of Victoria at Melbourne I, PETER WHITE, Coroner having investigated the death of:

Details of deccased: Sumame: HILL First name: STUART Address: 512/250 Barkly Street, Footscray, Victoria 3011

without holding an inquest: find that the identity of the deccased was STUART ANDREW HILL and death occurred on 22nd January, 2008

at Crown Street, Footscray, Victoria 3011

from la. DRUG OVERDOSE (PROPOFOL)

Pursuant to Section 67(2) of the Coroners Act 2008, an inquest into the death was not held and the deceased was not immediately before the person died, a person placed in custody or care; but there is a public interest to be served in making findings regarding the following circumstances:

  1. Mt Hill was 40 years old and had a history of anxiety and depression for which he had received medication. Ile worked casually as an Anaesthetic and Recovery Nurse from 20022008 at the Alfred Hospital. Mr Hill was in a de facto relationship with Mr Gumey Do-Carmo at Apartment 512, 250 Barkly Street, Footseray.

  2. On the 21st January 2008, Mr Hill and Mr Do-Carmo were in an argument and Mr Hill left the apartment in a depressed state after telling Mr Do-Carmo that he was going to kill himself. The following morning, on the 22nd day of January 2008, Mr Do-Carmo attended at the Footscray Police Station and reported Mr Hill missing before proceeding to look for Mr Hill and his vehicle, a grcen 95 Ford Futura sedan, registration number NMJ-284.

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  1. It is believed that Mr Hill, at an unknown time, travelled to his place of employment, being the Alfred Hospital, Commercial Road, Prahran, and obtained a quantity of various medicine containers which he had stored in his personal clothing locker.

4, On Tuesday, 22nd January, 2008, Mr Do-Carmo located Mr Hill’s vehicle in Crown Street, Footscray, (Crown Strect is located directly behind the block of apartments occupied by Mr Hill and Mr Do-Carmo) with Mr Hill in the driver’s seat in a reclined position.

  1. Ambulance and police aitended at the scene but life was extinct on their arrival. Police examined and photographed the scene and located a number of syringes and vials of drugs, namely Fresofol and Rocuronium in the passenger side footwell of the vehicle.

Finding

I find myself satisfied that on the 22nd January 2008, Mr Stuart Andrew IIill deliberately ended his own life while suffering from a depressive illness.

RECOMMENDATION: Pursuant to Section 72(2) of the Coroners Act 2008, I make the following recommendation connected with the death:

  1. While the Alfred Hospital cannot be expected to prevent all instances of theft of this kind, I recommend that details of this case be provided to those responsible for the management of unused anaesthetics at the Hospital with a view to giving cmphasis to the need for the ongoing careful auditing of unused supplies.

Signature: \ . gL, | fff Adcox Peter White ; ; / ai eh Las A Coroner \ Ale Mp a Sth October, 2011 13th September, 2011 . to bed b i DISTRIBUTION: ep

Family of Mr Stuart Hill

Mr Gurney Do-Carmo Administrator, Alfred Hospital

The Office of the Attorncy-General

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