Inquest into the Death of Doherty, Craig James
Deceased
Craig James Doherty
Demographics
39y, male
Date of death
2010-06-04/2010-06-07
Finding date
2013-09-05
Cause of death
propofol toxicity
AI-generated summary
Craig Doherty, a 39-year-old clinical theatre nurse at Royal Perth Hospital, died from propofol toxicity in June 2010. He had unrestricted access to propofol as an anaesthetic agent and misappropriated it for recreational use. Propofol was stored in unlocked cupboards with minimal monitoring or auditing requirements, unlike restricted Schedule 4 or Schedule 8 drugs. The coroner found that propofol's availability without adequate storage controls or accountability measures enabled the deceased to accumulate a large quantity. While Doherty had a prior suicide attempt in 2008, evidence supported an accidental rather than intentional overdose. Key clinical lessons include: propofol requires stricter controls despite operational complexity; healthcare institutions must implement accountability measures for high-risk drugs; staff with access to potent drugs require better monitoring; and technical solutions combined with physical security warrant consideration to balance emergency access with safety.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Drugs involved
Clinical conditions
Contributing factors
- unrestricted access to propofol as theatre nurse
- propofol stored in unlocked cupboards
- lack of monitoring or auditing of propofol stock
- propofol not classified as restricted Schedule 4 medicine
- no accountability measures for propofol distribution
- prior suicide attempt in 2008 with inadequate follow-up
- evidence of recreational propofol use indicated by puncture marks
- large quantity of hospital drugs and medical items in possession
- working as unauthorised agency nurse while employed at RPH
Coroner's recommendations
- The Department and all hospitals in the Western Australian health system implement a means of restricting the unauthorised use of propofol without placing patients at risk, if reasonably practicable. Possible approaches include: (1) classifying propofol as a restricted Schedule 4 medicine with exceptions for specified areas or circumstances; (2) locking propofol in secure cupboards with audits at end of each shift to maintain accountability; (3) providing additional pharmacy assistant resources to manage controls without burdening nursing staff; (4) utilising technological solutions such as automated medicine units with biometric identification and password access; (5) implementing swipe card access, locking theatre drug trolleys overnight, and using small drug safes in theatres.
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