The Florida clinic where a plastic surgeon's wife suffered cardiac arrest while he performed several cosmetic procedures on her was plagued with issues well before her death, according to a report.

An investigation conducted by the Florida Department of Health found that Dr. Benjamin Jacob Brown's Restore Plastic Surgery clinic in Gulf Breeze, Florida, first "began to decline" in 2021, a medical assistant told investigators.

The medical assistant alleged Brown broke protocol when he began to delegate more work to his physician assistant and his unlicensed wife, Hillary Ellington Brown, whose death he subsequently and allegedly caused.

The assistant also accused Brown of storing medication in an unlocked cabinet and purported staff would freely ingest Versed –– a sedative that promotes relaxation and sleepiness –– "to take the edge off" during their shifts, the 30-page report read.

As part of their investigation, the Department of Health spoke with two previous patients who claimed they went to Brown for liposuction and breast implant surgeries, and received unauthorized Brazilian butt lifts –– a procedure where fat is transferred to the patient's buttocks –– while under the knife.

When one of the patients confronted him, Brown allegedly admitted to the surgery because he thought she would "love it," according to the report.

Investigators found Brown's clinic also allegedly failed to maintain proper medical records and documentation pertaining to patient appointments and procedures.

On Monday, Brown was arrested and charged with second-degree felony homicide in connection with Hillary's death, according to the Santa Rosa County Sheriff's Office.

The mom of three died in November 2023, one week after she was admitted to the hospital for cardiac arrest experienced while her husband performed a scar revision, arm liposuction, lip injections, and ear adjustment procedures, according to investigation records.

Prior to the operations, Hillary administered her own "handful" of undocumented, "multi-colored pills," which included Valium, investigators discovered. She also prepared her own IV solution, despite not having a license to do so.

While on the operating table, Hillary displayed symptoms of lidocaine toxicity caused by an overdose of the anesthetic, triggering a seizure and cardiac arrest.

Brown allegedly instructed his staff to hold off from calling 911 for 20 minutes. His wife never regained consciousness.

"My family lives in a sea of tears for eternity due to the actions of one careless individual," Hillary's dad, Marty Ellington said, according to the Pensacola News Journal. "His ego and arrogance overshadowed the need for help, prolonging oxygen deprivation to her brain and ultimately causing her death. Ben Brown took the mother from my grandchildren, my only daughter and our brightest star. Hillary gave the ultimate sacrifice so Ben Brown cannot hurt anyone else. Maybe in prison, he will get the attention he deserves."