Finding into death of H S

IN THE CORONERS COURT COR 2023 002689 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Ingrid Giles Deceased: Mr HS1 Date of birth: 1973 Date of death: On or between 18 and 20 May 2023 Cause of death: 1a: ACUTE ALCOHOL TOXICITY Place of death: Oaks Melbourne on Collins Hotel, 608/480 Collins Street, Melbourne, Victoria, 3004 Keywords: Alcohol toxicity, chronic alcoholism, ethanol, heavy alcohol consumption, alcohol harm reduction 1 This Finding has been de-identified by order of Coroner Ingrid Giles which includes an order to replace the name of the deceased, and the names of other persons related to or associated with the deceased, with a pseudonym of a randomly generated letter sequence for the purposes of publication.

INTRODUCTION

1. On 20 May 2023, Mr HS was 50 years old when he was located deceased in a hotel room in Melbourne. At the time of his death, Mr HS lived in Blackburn, Victoria, 3130.

Background

2. While studying at university, Mr HS met Ms LS whom he went on to marry and welcome three children. In 2010, Mr HS took over the business which he previously shared with his brother.

3. It was not until around 2013 that Mr HS’s alcohol consumption increased. According to Ms LS, he was ‘drinking a few bottles of wine over the weekend’ and lost his driver licence due to driving while intoxicated.

4. In 2016, Mr HS began drinking vodka instead of wine and was drinking ‘most nights’. Mr HS was secretive regarding his alcohol consumption: ‘Mr HS also started hiding bottles of vodka around the house. [. . . ] He was very sneaky with it and would try and hide the vodka sometimes by putting it in water bottles or mixing it with water’.

5. Evidence indicates that in 2018, Mr HS started spending more time with a colleague, Ms EM.

6. From 2019, Mr HS’s alcohol consumption continued to escalate – he began drinking at work and would return home intoxicated. Ms LS believed that he was under increasing pressure at work: ‘the business was continuing to grow, and it was a lot for him to manage’. It was around this time that Mr HS first engaged with a rehabilitation program. He attended a four-week program in New South Wales and returned home ‘a changed man’; however, he recommenced consuming alcohol after approximately four days.

7. In 2020 and 2021, Mr HS made further attempts to curb his alcohol consumption through different rehabilitation programs. On each occasion, Ms LS recalled that he either left the programs early, or relapsed shortly after their conclusion.

8. In 2021, Ms LS asked Mr HS to move out of their family home in order to shield their three children from witnessing his alcohol consumption.

9. Throughout late 2022, Mr HS had several presentations to Box Hill Hospital and Maroondah Hospital and on each occasion was either intoxicated or had recently consumed alcohol. On

11 June 2022, bystanders located him in an altered conscious state at a train station. Mr HS informed paramedics that he had consumed alcohol that day.

10. On 11 August 2022, Mr HS was discovered at home with a laceration to his head, having consumed half a bottle of vodka and half a bottle of wine. One week later, on 18 August 2022, Mr HS reportedly telephoned his mother and expressed suicidal ideation, and that he had consumed three-quarters of a bottle of vodka. Mr HS’s mother contacted emergency services and Mr HS was transported to Maroondah Hospital.

11. On 14 December 2022, Mr HS was again discovered intoxicated at a train station. He told paramedics that he was experiencing suicidal ideation and had devised a plan to act on the same. Mr HS stated he had consumed two bottles of wine, and a half-empty bottle of vodka was located in his bag.

12. Mr HS’s most recent presentation occurred on 9 January 2022. He attended Maroondah Hospital with a minor head injury and told clinicians he had ‘probably fell as [he had] been drinking a lot [that day]’. He elaborated that he often had ‘benders’ and that he would not consume alcohol for a few days, then consume large volumes across subsequent days. He told paramedics that he consumed alcohol to assist his mental ill health, and that he experienced suicidal ideation on a daily basis.

13. In 2022 or 2023, Mr HS’s employment was terminated. Ms EM recalled he was ‘very depressed’ and continued consuming alcohol.

14. Ms LS’s recollection is slightly different, opining that Mr HS did not experience mental ill health: ‘Mr HS was never suicidal, and he never said he was depressed’. He was prescribed diazepam to assist in maintaining sobriety, and there is no indication that he consumed it excessively (in fact, he reportedly demonstrated an avoidance of prescription medication).

15. I note that Ms LS recalls that Mr HS, during this period, was attempting to ‘get his life back on track’.

THE CORONIAL INVESTIGATION

16. Mr HS’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

17. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

18. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

19. Victoria Police assigned an officer to be the Coronial Investigator for the investigation of Mr HS’s death. The Coronial Investigator conducted inquiries on the Court’s behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

20. Deputy State Coroner Spanos initially held carriage of the investigation into Mr HS’s death until it came under my purview in July 2023 for the purposes of obtaining further information, finalising the investigation and handing down this finding.

21. This finding draws on the totality of the coronial investigation into the death of Mr HS including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.2

CIRCUMSTANCES IN WHICH THE DEATH OCCURRED

22. On 17 May 2023, Mr HS and Ms EM spoke on the phone and she told him ‘there’s no more drinking at [her] place. [She] then told him he either had to stop drinking or [leave]’. Mr HS elected to book a hotel room at the Oaks Melbourne on Collins Suites (the Oaks).

23. That evening, Mr HS and Ms LS spoke on the phone. Mr HS informed her that he ‘was planning on going to Thailand (. . . ) because he felt like there was nothing for him [in 2 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

Melbourne]’. According to Ms LS, Mr HS was ‘very sad, but never said anything about being depressed or suicidal’.

24. The following morning on 18 May 2023, Ms EM attempted to convince Mr HS to return home. He replied that ‘he still had three more nights booked at his hotel, so he was going to stay there until he checks out’. During this phone conversation, Mr HS ‘sounded hungover’ but ‘seemed happy that [Ms EM] was asking him to come back’.

25. Later the same day, Ms EM made repeated attempts to telephone Mr HS, but he did not answer.

26. On 20 May 2023, at approximately 11:23am, a staff member of the Oaks entered Mr HS’s room and ‘sighted someone was on the floor’. The staff member informed their supervisor, who attended Mr HS’s room and contacted emergency services.

27. Ambulance Victoria attended the scene and declared Mr HS deceased.

28. Victoria Police members attended the scene and located two 700mL bottles of vodka – one empty and one more than half empty. Members obtained data which demonstrated that Mr HS last entered his hotel room at 4:45pm on 18 May 2023. At 4:45pm and 4:46pm, internal doors within the hotel room were used. There was no further activity of the hotel room’s front door or internal doors after this time, until staff entered on 20 May 2023.

IDENTITY OF THE DECEASED

29. On 24 May 2023, Mr HS (whose full name is known to the Court), born 13 January 1973, was visually identified by his spouse, Ms LS, who completed a formal Statement of Identification.

30. Identity is not in dispute and requires no further investigation.

MEDICAL CAUSE OF DEATH

31. Forensic Pathologist Dr Gregory Young (Dr Young) of the Victorian Institute of Forensic Medicine (VIFM) conducted an autopsy on the body of Mr HS on 23 May 2023. Dr Young considered materials including the Victoria Police Report of Death for the Coroner (Form 83) and post-mortem computed tomography (CT) scan and provided a written report of his findings dated 30 June 2023.

32. The post-mortem examination revealed mild hepatic steatosis – colloquially known as ‘fatty liver’ – which Dr Young stated is often seen in the context of high alcohol consumption. There was no significant natural disease nor injuries which could have caused or contributed to the death.

33. Toxicological analysis of post-mortem samples identified the presence of: Ethanol (alcohol) 0.40 g/100mL of blood Ethanol (alcohol) 0.60 g/100mL of vitreous humour3

34. Dr Young stated that blood alcohol at a level of 0.40 g/100 mL is high and is a concentration that may lead to death due to paralysis of the respiratory centres in the brain.

35. Dr Young provided an opinion that the medical cause of death was 1(a) acute alcohol toxicity.

36. I accept Dr Young’s opinion.

THE PREVALENCE OF ALCOHOL-RELATED HARM AND ASSOCIATED PREVENTION STRATEGIES IN VICTORIA

37. As I noted in the recently-published finding into the death of Kathleen Arnold,4 in my role as a coroner, I regularly encounter the fatal consequences of alcohol use among the Victorian community. Each year more than 150 deaths involving the acute toxic effects of alcohol are reported to the Coroners Court of Victoria. At least another 100 deaths reported each year are caused by the chronic effects of alcohol use. However, these deaths represent only a proportion of all alcohol-related deaths, as most deaths resulting from chronic alcohol use are not reportable under the Coroners Act 2008 (Vic), given they are largely classified as deaths that are due to ‘natural causes’ and therefore, unless they are also ‘unexpected’, will not usually be reported to the coroner.

38. More broadly, alcohol is a factor in a myriad of deaths in the absence of the complications of chronic consumption. Such circumstances include homicides where alcohol use was implicated; suicides of people who had a history of alcohol use and/or who were alcohol 3 Vitreous humour is the clear gel that fills the space between the lens and the retina of the eyeball. Generally, toxicological analysis of vitreous humour provides a better indicator of perimortem levels than post-mortem blood.

4 Finding into death without Inquest, 11 February 2025, COR 2023 5162, available here: https://www.coronerscourt.vic.gov.au/sites/default/files/2025-02/COR%202023%20005162%20Form%2038%20- %20Finding%20into%20Death%20without%20Inquest.pdf.

affected; fatal motor vehicle collisions where a driver or other involved person was affected by alcohol; drownings of people intoxicated by alcohol; and many others.

39. To explore what might be done to address the deadly toll of alcohol in the Victorian community, I commenced an analysis of certain of the deaths I am currently investigating in which the person, prior to death, had been engaged in alcohol use for an extended period, and the death was the direct result of alcohol consumption. My hope was that, through examining the circumstances of deaths falling into this broad category, I might be able to identify some commonalities pointing to potential areas for intervention to reduce alcohol-related harms.

40. However, from review of the material I was unable to identify any meaningful commonalities.

The alcohol-related deaths under my investigation were of people who had diverse sociodemographic profiles, patterns of alcohol use, mental health histories, and histories of engagement in treatment for alcohol related harms. They died in diverse circumstances linked to their alcohol use, reflecting the diverse ways tin which alcohol can cause harms across the Victorian community.

41. I then resolved to approach the investigation from a different direction, looking at what inquiries and reviews Victorian and Commonwealth governments had conducted over time to explore how to address alcohol-related harms, in the hope that I might identify any potential prevention opportunities among these. The Coroners Prevention Unit (CPU)5 assisted me to identify relevant initiatives, which included the following: i. The Parliament of Victoria Drugs and Crime Prevention Committee’s Inquiry into Strategies to Reduce Harmful Alcohol Consumption (Inquiry), which delivered its final report in March 2006 after two years of consultation and work;6 ii. The Victorian Government’s Alcohol Action Plan 2008-2013, which was published in May 2008 by the Victorian Department of Health and described specific actions to be taken as well as a broader framework for change to address alcohol misuse in Victoria;7 5 The CPU was established in 2008 to strengthen the coroners’ prevention role and assist in formulating recommendations following a death. The CPU is comprised of health professionals and personnel with experience in a range of areas including medicine, nursing, mental health, public health, family violence and other generalist non-clinical matters.

The unit may review the medical care and treatment in cases referred by the coroner, as well as assist with research related to public health and safety including by providing data and statistics into the prevalence of certain deaths.

6 Parliament of Victoria Drugs and Crime Prevention Committee, Inquiry into Strategies to Reduce Harmful Alcohol Consumption: Final Report. Volumes 1 and 2, and the Response to the Final Report, published on 23 March 2006.

Accessible at: Reports - Inquiry into strategies to reduce harmful alcohol consumption - Parliament of Victoria.

7 Ministerial Taskforce on Alcohol and Public Safety, Restoring the balance: Victoria's Alcohol Action Plan 2008-2013, published May 2008. Accessible at: Victoria's Alcohol Action Plan 2008-2013 - May 2008.

iii. The Victorian Auditor-General’s Office report “Effectiveness of Justice Strategies in Preventing and Reducing Alcohol-Related Harm”, published in June 2012, which examined the roles of Victoria Police, the Department of Justice and the Victorian Commission for Gambling and Liquor Regulation in preventing and reducing alcoholrelated harm in Victoria;8 iv. The VicHealth Alcohol Strategy 2019-2023, which was published in August 2019;9 and v. The Australian Government Department of Health and Aged Care’s National Alcohol Strategy 2019-2028, published in December 2019, which was intended to guide state and territory governments as well as communities and health service providers in their responses to alcohol-related harms. This succeeded the National Alcohol Strategy 20062011 (there was no strategy in place during the intervening period 2012-2018).10

42. Additionally, noting that the Australian Parliament Standing Committee on Health, Aged Care and Sport is currently conducting an Inquiry into the Health Impacts of Alcohol and Other Drugs in Australia (the Inquiry),11 I considered the submissions received to date, in particular the submission of Alcohol Change Australia.12 I acknowledge there are many excellent submissions to this Inquiry; I selected the Alcohol Change Australia submission for review because: (i) it specifically addresses alcohol-related harms; and (ii) the member organisations of Alcohol Change Australia include a number of highly respected public health bodies.

43. In reviewing the material, I was struck by the fact that despite these initiatives occurring over a 20-year time span, there was nonetheless a high degree of concordance between them regarding what needs to be done to reduce alcohol-related harms. The following broad areas were consistently identified as requiring action (though not every area was addressed in every document): 8 Victorian Auditor-General’s Office, Effectiveness of Justice Strategies in Preventing and Reducing Alcohol-Related Harm, tabled on 20 June 2012. Accessible at: Effectiveness of Justice Strategies in Preventing and Reducing AlcoholRelated Harm | Victorian Auditor-General's Office.

9 VicHealth, Alcohol Strategy 2019-2023, published 5 August 2019. Accessible at: VicHealth Alcohol Strategy 2019– 2023 | VicHealth.

10 Australian Government Department of Health, National Alcohol Strategy 2019-2028, Canberra: Department of Health published December 2019. Accessible at: National Alcohol Strategy 2019–2028 | Australian Government Department of Health and Aged Care.

11 See in this regard Inquiry into the health impacts of alcohol and other drugs in Australia – Parliament of Australia.

12 Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions.

i. Pricing: Alcohol prices can influence risky alcohol use and associated harms, and changes to pricing may reduce harms.

ii. Taxation: Different types of alcohol products are taxed differently at present in Australia, and some taxation arrangements contribute to harmful alcohol use. Changes to how alcohol is taxed may reduce harms.13 iii. Regulation: The way that alcohol is made available (through sale and service) to the Victorian community is subject to regulatory controls. There are a number of areas (including but not limited to density of venues where alcohol is served or sold, times when alcohol is available, ways alcohol can be purchased, enforcement of regulations relating to alcohol service and sale, training requirements for those who serve or sell alcohol, and permitted types of alcohol promotions) where changes to regulation may reduce harms associated with alcohol use.

iv. Healthcare: It is critical to ensure that appropriate treatment is available in a timely manner to persons experiencing alcohol dependence or other alcohol-related health problems, and/or who are seeking assistance to reduce or cease alcohol use. This includes early intervention programs to support persons who may be at risk of harmful alcohol use.

v. Advertising: There are links between advertising and other alcohol promotion (for example via sponsorships) and harmful alcohol use. Advertising restrictions may be a potent harm reduction initiative, particularly if they result in a reduction in young people’s exposure to alcohol product advertising. 14 vi. Product labelling: Alcohol drink containers present opportunities to communicate information about alcohol use and its health impacts.15 13 For completeness, some alcohols (such as beer and spirits) are taxed proportionately to their alcohol content while other alcohols (such as wines) are taxed based on their price. As such, cheaper wine products are taxed less than premium wines, despite that their alcohol concentrations may be the same. Submissions of Alcohol Change Australia identify that ‘high-volume, high-alcohol wine (such as cask wine) is often being sold at low prices’ (see Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions at page 7).

14 See in this regard Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 6.

15 See in this regard Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 7-8.

vii. Education for young Victorians: There is a strong imperative to ensure that in schools and other contexts, young people are provided appropriate and effective education in responsible alcohol use and alcohol-related harms.16 viii. Community education: The negative impacts of alcohol use in the Victorian community may be addressed by taking action to increase general awareness about individual, family and community harms associated with alcohol consumption, and how to prevent or reduce them.17 ix. Social attitudes towards alcohol: Certain social attitudes support harmful alcohol consumption, such as the expectation that alcohol is consumed on social occasions and at celebratory events, and tolerance of high consumption levels. If these social attitudes can be changed, harmful alcohol use can be reduced.

44. Recognition of the need for action across these areas appears to extend back even further in time than the period I examined. I note that back in 2006, the Drugs and Crime Prevention Committee were already declaring that: ‘There is now general agreement in both the national and international literature as to what is the most effective range of responses available to policymakers to address alcohol-related harms.’18

45. This was echoed in the 2024 Alcohol Change Australia submissions to the Inquiry that: ‘We know what works and it is time to implement a systematic, coordinated and evidence-based approach to reduce harm from alcohol in Australia.’19 16 See in this regard Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 6. The need for education for young Victorians is also reflected in the recent finding of Coroner Catherine Fitzgerald in relation to the death of a 16year-old boy from complications of acute alcohol intoxication – see in this regard the Finding into death without Inquest of LG, 12 December 2024. Accessible at: https://www.coronerscourt.vic.gov.au/sites/default/files/New Deidentified COR%202022%20007423%20Form%2038%20-20Finding%20into%20Death%20without%20Inquest.pdf 17 See in this regard Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 7-9.

18 Parliament of Victoria Drugs and Crime Prevention Committee, Inquiry into Strategies to Reduce Harmful Alcohol Consumption: Final Report, Volume 1. Accessible at: Reports - Inquiry into strategies to reduce harmful alcohol consumption - Parliament of Victoria, page xi.

19 Alcohol Change Australia, Inquiry into the health impacts of alcohol and other drugs in Australia - Submission 76, December 2024, accessed via https://www.aph.gov.au/Parliamentary Business/ Committees/House/Health Aged Care and Sport/Alcoholanddrugs/Submissions page 2.

46. This 2024 call to action, nearly two decades on from the Drugs and Crime Prevention Committee’s final report, led me to examine how the Victorian Government is currently coordinating its efforts to reduce alcohol related harms.

47. In particular, I noted that after the Victorian Government’s Alcohol Action Plan 2008-2013 expired, there did not appear to be any follow-up action plan to build on what was trialled, implemented and achieved. This was to my mind unfortunate, given that effecting change in such diverse domains as social attitudes, community education and regulation requires sustained effort. The Drugs and Crime Prevention Committee observed in 2006 that: ‘In an area as complex as alcohol and other drug policy it is neither possible nor desirable to achieve sustainable and long term change overnight. Incremental or gradual change is not only the most feasible way of moving forward but also the most desirable. As well, it is an approach that recognises community attitudes and the reality of the political and bureaucratic environments in which policy change occurs.’20

48. Perhaps efforts to renew the Victorian Alcohol Action Plan were redirected towards the development of the National Alcohol Strategy 2019-2028, which was endorsed by State and Territory governments. However, if this is the case, it raises a further question about what Victoria has done under the auspices of the National Alcohol Strategy 2019-2028, noting the Strategy emphasises the central role of States and Territories in implementation: ‘Jurisdictional implementation allows for governments to take action relevant to their jurisdiction with a national harm minimisation approach and strategies should reflect local circumstances and address emerging issues and drug types. It is expected that jurisdictions will prioritise actions that are evidence-informed and demonstrated to have the greatest impact on preventing and reducing alcohol-related harms.’21

49. While the National Alcohol Strategy 2019-2028 describes a regular reporting framework to measure Strategy effectiveness and progress,22 I have been unable to source any publiclyavailable reports describing Victoria’s actions under the Strategy or progress towards goals.

20 Parliament of Victoria Drugs and Crime Prevention Committee, Inquiry into Strategies to Reduce Harmful Alcohol Consumption: Final Report, Volume 1. Accessible at: Reports - Inquiry into strategies to reduce harmful alcohol consumption - Parliament of Victoria, page xiii.

21 Australian Government Department of Health and Aged Care, National Alcohol Strategy 2019-2028, published in December 2019. Accessible at: National Alcohol Strategy 2019–2028 | Australian Government Department of Health and Aged Care, page 13.

22 Ibid at page 32.

Further to this point, my attention was directed to an April 2024 report in which Alcohol Change Australia documented a ‘lack of public monitoring or reporting’23 relating to the Strategy, and conducted their own analysis of the Strategy to establish that: ‘There has been minimal or no change in alcohol use and harms across a range of indicators since the Strategy was introduced in 2019.’24

50. I draw no conclusions from this about what actions Victoria has, or has not, taken under the auspices of the National Alcohol Strategy 2019-2028, nor their merits or effectiveness.

However, this situation clearly highlights the need for Victoria to lead its own program of work (whether described as a ‘strategy’, an ‘action plan’ or otherwise) to address alcoholrelated harms in the community. This program of work should describe what specific actions are undertaken, the timeframes within which they should be implemented, who is responsible for them, and how they will be evaluated for effectiveness. It should also incorporate public reporting on implementation and evaluation of these actions to address alcohol-related harms.

I expect that identifying and prioritising actions to be undertaken within the program of work will be straightforward; as already discussed, there is longstanding consensus on what needs to be done.

51. The Victorian Government announced in April 2024 that it would develop a new 10-year strategy to address alcohol and other drug harms. I understand that early work has already commenced, including stakeholder consultations to inform strategy development.25 This could potentially be the vehicle for developing the program of work described above, however, as the scope and outcomes of the strategy have not yet been formalised, I cannot confirm whether this is the case. Therefore, a pertinent comment will be made in this respect.

FINDINGS AND CONCLUSION

52. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Mr HS (whose full name is known to the Court), born 1973; 23 Alcohol Change Australia, A Mid-Point Review of the National Alcohol Strategy 2019-2028: How is Australia tracking on reducing alcohol use and harms? Published April 2024 and accessible at Alcohol-Change-Australia-report-A-midpoint-review-of-the-National-Alcohol-Strategy-April24.pdf page 2.

24 Ibid.

25 Victorian Government Department of Health, ‘Alcohol and Other Drug Strategy: What we heard overview’, November

2024. Accessible at: https://www.vaada.org.au/wp-content/uploads/2024/12/AOD-Strategy-What-We-Heardoverview.pdf.

b) the death occurred on or between 18 and 20 May 2023 at Oaks Melbourne on Collins Hotel, 608/480 Collins Street, Melbourne, Victoria, 3004, from 1(a) acute alcohol toxicity; and c) the death occurred in the circumstances described above.

53. Having considered all of the circumstances, I find that Mr HS’s death occurred in the context of an extended history of excess alcohol consumption. While he was experiencing relationship, employment and other stressors, and had previously experienced suicidal ideation, there is no evidence to indicate that Mr HS consumed the alcohol that caused his death with the intention to take his own life. I do however consider that the circumstances of his death suggest a degree of recklessness regarding the potentially fatal consequences of excess alcohol consumption.

54. I note that Mr HS engaged with rehabilitation programs in the years leading up to his death and that, at times, indicated an intention to cease or reduce his alcohol consumption.

However, evidence indicates that these efforts resulted in shorter-term periods of abstinence and that Mr HS resumed consuming alcohol after each attempt to cease. His frequent interface with health and rehabilitation services represented opportunities for intervention in the course of his addiction, but sadly, he was not well positioned to avail himself of those opportunities in an ongoing manner prior to his death.

55. In this connection, having made comments about the prevalence of alcohol-related harm in the Victorian community, I consider that the circumstances of Mr HS’s death bring into focus a range of prevention opportunities in this sector.

I convey my sincere condolences to Mr HS’s family for their loss.

COMMENT Pursuant to section 67(3) of the Act, I make the following comment:

1. I note that I recently handed down three recommendations in my Finding without Inquest into the Death of Kathleen Arnold, who similarly died in circumstances of alcohol toxicity.26 The recommendation relevant to the present finding is ‘that the Victorian Government, led by the 26 Finding into death without Inquest into the Death of Kathleen Arnold (COR 2023 005162), dated 11 February 2025, COR 2023 5162, Accessible at: https://www.coronerscourt.vic.gov.au/sites/default/files/202502/COR%202023%20005162%20Form%2038%20-%20Finding%20into%20Death%20without%20Inquest.pdf.

Victorian Department of Health, develop: (i) a new Alcohol Action Plan; or (ii) a program of work (including specific actions, timeframes, accountabilities, and public reporting on implementation and evaluation) to address alcohol-related harms in Victoria’.

2. I have noted this recommendation in Mr HS’ finding for the purposes of completeness and to reflect the range of circumstances in which people in this State die, very tragically, from the effects of alcohol, which underpins the need for a range of strategies to address alcohol-related harm in all its various forms. The Victorian Government and Department of Health may wish to consider and provide comment on Mr HS’ death in the context of their responses to this recommendation, which are due to be received on or around 12 May 2025.

ORDERS AND DIRECTIONS Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: Ms LS, Senior Next of Kin Victorian Department of Justice and Community Safety Victorian Department of Health Australian Government Department of Health and Aged Care Victorian Alcohol and Drug Association Alcohol Change Victoria Alcohol Change Australia FARE Australia Sergeant Kayne Ewin, Coronial Investigator