Sheriff: Addict's death was 'preventable'

Valium addict Kieran Nichol, 20, was put on the heroin substitute shortly after being re-admitted to Castle Craig Hospital at Blyth Bridge in the Borders after he claimed to be addicted to heroin.

The inquiry heard Mr Nichol had spent six weeks "detoxing" at the clinic before discharging himself in October, 2005 but two months later he lapsed back into depression and drug use and his mother Jacqueline Nichol, 49, rang the hospital to ask for her son to be re-admitted and he was taken in the following day on 9 December . He died two days later.

Sheriff Gordon Liddle said in his determination following a fatal accident inquiry at Edinburgh Sheriff Court that a "different decision or choice by a number of individuals could have made the difference".

He added that it was "difficult to identify anything that went significantly well".

Mr Nichol was given three doses of methadone totalling 90mg in 24 hours.

An addictions specialist told the inquiry the dosage was "too high" given the uncertainty about Mr Nichol's tolerance level.

The sheriff said following the death the hospital, partly at the insistence of the Care Commission, made a number of changes. He also outlined a further number of recommendations in his determination including that altering any prescribed dose of methadone should remain, at all times, with those qualified to prescribe that drug.

The court heard Mr Nichol told clinic staff he had developed a 60-a-day heroin habit in less than two months but Mrs Nichol, a nurse, told the inquiry her son had only smoked heroin twice and was not addicted to the drug.

The inquiry was also told no urine sample was taken from Mr Nichol to check for heroin use before he was prescribed methadone and diazepam by the Castle Craig doctor, David McCartney, himself a former heroin addict.

Dr McCartney had been "clean" for two years when he prescribed an initial dose of 30mg of methadone and two further doses of 30mg for the following day, which was approved by a senior doctor. The three doses were then given to Mr Nichol by nurses despite him showing signs of being over-medicated. Dr McCartney, who now heads the Lothians and Edinburgh Abstinence Programme (LEAP), said his own experience of heroin addict had given him greater empathy and a heightened awareness to the difficulties faced by addicts trying to come off drugs.

Giving evidence at the inquiry a professor of nursing described as "extraordinary" the decision by a hospital to put Mr Nichol to bed and tell him to sleep when he was about to lapse into a coma.

Kevin Gournay said it should have been clear to nursing staff that he was "becoming a medical emergency" after being given an overdose of methadone. Hours after being given the third dose he was drowsy, staggering around and unable to pass urine and had to be helped upstairs by three people where he was told to go to bed and sleep.

Professor Gournay, now retired, said the nurse on duty should have called the doctor or even 999.

"There is just an amazing array of things that would alert any reasonable person working in a detoxification centre to be very worried – it is becoming a medical emergency.

"Its just so extraordinary that this young man was just left to his own devices," said Professor Gournay.

Sheriff Liddle described the death as "a tragedy". He said: "It is especially so for his family.

"I have sympathy for family and particular sympathy for his mother, who sat through the many days of evidence and, an experienced nurse herself, must have been very alert to all of the issues that arose.

"She could scarcely have imagined that what she at the time saw as a rescue exercise for her son, namely getting him rapidly back into Castle Craig Hospital, might turn out as it did."

In his determination the sheriff also criticised the Crown saying the point of the inquiry was to discover what has happened and why it happened.

He said: "That is in order to prevent a recurrence of such a tragedy.

"I regret to say that I regard the Crown position, in relation to those central witnesses not led, to have been unhelpful." He pointed to the fact that those immediately responsible for the care of Mr Nichol at the time of death, namely Dr Lal Sharma and Nurse William Wood, were not led in evidence by the Crown. "This is a very unusual and unsatisfactory state of affairs", he said.

He also said: "There remain questions unanswered.

"It is all the more surprising considering that it took from December 2005 to April 2009 for the Inquiry to commence with the Crown position in relation to witnesses still unresolved.

"I hope that this inquiry has been able to provide enough insight as to how the death occurred and that it might assist, in whatever can be learned from it, in death in similar circumstances in the future being avoided."

Mrs Nichol told the court she had been very concerned about her son's state of mind and his mental health before he was taken back into Castle Craigs. "He was upset and crying and saying he needed help," she said.

Two days later on 11 December, police arrived at her home in Weensland Road, Hawick, to say her son had died. To be told less than 48 hours later he's died in their care, yes we were shocked," said Mrs Nichol. "It had a psychological effect on all the family."

Today she said: "Sheriff Gordon Liddle has done an excellent job, he has done all he could at this stage.

"There are still questions which need to be answered and it is about what is best for the public now.

"It shouldn't take until a young man dies before changes are made. It has been a long haul but we will keep looking for answers and we are getting there."