EARLY on the morning of September 29, 2010, Grace Yates, then 23 and the mother of a five-month-old baby girl, was dropped off, with her fiance, at a clinic in the side streets of Ultimo for a procedure she hoped would turn her life around.
A former heroin addict who had been on a legal methadone program for four years, Yates was counting on a seeming miracle treatment promoted by the clinic's director, Dr Ross Colquhoun, to free her from methadone dependency.
At 5.20pm, after treatment at the clinic, she suffered a heart attack and collapsed. Taken to Royal Prince Alfred Hospital, she never regained consciousness, and died two months later.
Almost two years to the day after her treatment, on September 27, a report handed down by the State Coroner, Mary Jerram, has slammed the clinic - called Psych 'n' Soul - for its ''abysmal'' aftercare of Yates and another patient, Michael Poole, who also died soon after treatment.
Neither Yates nor Poole were suitable for the experimental treatment using surgical implants of naltrexone, the coroner found. In Yates's case, an electrocardiogram that revealed her underlying heart condition did not raise a red flag for the clinic's poorly trained and undersupervised staff.
''I'm never going to get over this,'' her former fiance, David Anjoul, says. ''She was only 23, a beautiful girl in every way, trying to get her life back. We had our lovely baby, Tobei, who is two now. It just crushes me every day to know that she won't have her mother as she is growing up.''
A third patient, James Unicomb, died three months after treatment at the clinic in 2005. The coroner found that while Unicomb's death was not directly linked with the implant, he had not been ''entirely suitable'' for the treatment, and she cited expert evidence that ''medical assessment at the clinic was grossly inadequate''.
The Herald has since spoken with a fourth family, the Pattersons, whose daughter ''Sue'' nearly died three days after undergoing the treatment, known as rapid opioid detoxification, or ROD, at the clinic in 2006.
Sue's mother, Tania Patterson, who doesn't wish to give her daughter's full name, says the family was promised round-the-clock back-up over three months for the $4700 they paid.
The reality was very different. There was one follow-up call by the clinic the day after treatment. Mrs Patterson says that three days later, when Sue was rushed to intensive care suffering acute renal failure, Dr Colquhoun spoke to her and doctors at Nepean hospital some hours after she had left urgent messages for him.
Subsequently, she claims, the clinic did not initiate any other contact. Weeks later, her daughter booked in for several counselling sessions at the clinic but gave up attending because she could not bear going back to a place she associated with such trauma.
Sue is now in a ''difficult place'', her mother says, and the whole family has been ''scarred''.
Dr Colquhoun would not provide an on-the-record response. He put the Herald in touch with another former addict, Caitlin Prasser, who says she owes her recovery to him.
The clinic stopped on-site ROD treatment in 2010 after Yates's death but it continues to offer naltrexone implants for patients who have been detoxed elsewhere, a source at the clinic said.
Dr Colquhoun had previously been warned by the NSW Health Department that he did not have a licence for ROD treatment. Oral naltrexone is approved for use by alcoholics but implants of the drug for opiate addiction are highly controversial.
Dr Alex Wodak, an addiction expert and emeritus consultant at St Vincent's hospital, says Russia is the only country to officially approve naltrexone implants for heroin dependence.
Dr Wodak is critical of a loophole in federal government rules that allow addicts to have naltrexone implants . He says it is an ''experimental and fringe'' treatment that should be suspended until proper medical trials have been conducted.
''In my view its not really [just] about Colquhoun; it's about the lack of regulation of implants,'' he says. ''Ross Colquhoun should never have been allowed to happen … and should never have been allowed to continue.''
Records of the Health Care Complaints Commission show a string of adverse findings against the clinic, and some of its staff, since 2009. Dr Donald Tan was found guilty of unsatisfactory professional conduct and ordered not to perform any more rapid opioid detoxification procedures.
Another doctor who worked there is being examined by the commission and a third has been been referred by the coroner for possible proceedings.
A nurse, Philippe Jacquot, was found guilty of unsatisfactory professional conduct in April last year. He told the nursing and midwifery professional standards committee he had formed the view that the clinic was a ''money spinner'' and ''inhumane''.
Last year, Dr Colquhoun, who is not a medical doctor but holds a doctorate in health sciences, successfully appealed a decision by the Psychology Council of NSW in 2010 to suspend his registration, but he is the subject of separate disciplinary proceedings.
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