By Anna Walsh and Divya Pahwa
NSW State Coroner Magistrate Mary Jerram held a five day inquest into the deaths of Grace Yates, Michael Poole and James Unicomb in late August, 2012.
All three people died after they underwent rapid opioid detoxification (ROD) treatment for their drug dependencies at the Psych 'n' Soul Clinic, a private health facility in Ultimo, Sydney owned and managed by Dr Ross Colquhoun, psychologist. This treatment involves administration of an opioid antagonist such as naloxone or naltrexone while providing symptomatic relief to enable patients to tolerate the procedure.
Maurice Blackburn represented the interests of the family of Grace Yates, 24 at the inquest. Grace was a high risk patient and an inappropriate candidate for ROD as she had an underlying heart condition. This was not given any consideration by Dr Shinwari, general practitioner who medically assessed Grace prior to the treatment.
Grace suffered a cardiac arrest while undergoing ROD at the clinic on 29 September, 2010. Attempts were made to resuscitate Grace at the Clinic before the ambulance arrived. She was taken to Royal Prince Alfred Hospital in a coma. She suffered from hypoxic ischaemic encephalopathy and ultimately died on 30 November, 2010 from acute broncho-pneumonia secondary to the hypoxic event which in turn was a result of the cardiac arrest following the ROD treatment.
Interestingly Dr Shinwari and Dr Colquhoun were excused from giving evidence at the Inquest on the basis that they could be liable for a civil penalty in respect of outstanding proceedings against them from the Health Care Complaints Commission.
Despite this, the Coroner handed down very strong findings on 27 September 2012 that were critical of the poor assessment of Grace given her cardiac condition was a contraindication to such treatment. She made severe criticisms of the nursing care provided to Grace by untrained and unsupervised nursing staff, who did not know how to resuscitate or how to use the defibrillator machine that was available. Ultimately, the Coroner described the care as 'abysmal'.
Although protocols and legislation were in place in the management of such treatment, they were not followed by the Clinic. The Clinic was not licensed to perform ROD treatment as required under legislation. Dr Ross Colquhoun was made aware of the licensing requirements by the Department of Health and even provided an undertaking not to perform ROD treatment until a licence was granted.
Grace left behind a 2 year old daughter. The Coroner noted that Grace's intention in seeking the treatment arose from a strong motivation to cure herself of her addictions for her daughter's sake. The case generated much media interest and raised issues about the use of naltrexone implants "off label", the need for proper consent procedures and advice and information to patients about the risks of treatment and the need to advise patients of alternate options for the treatment of drug addiction. No doubt the interest raised through this Inquest and the Coroner's findings can only improve medical practice and hopefully prevent such tragedies happening again.