Inquest into the deaths of James UNICOMBE, Michael POOLE, Grace YATES

Three deaths with different primary causes: James Unicomb - acute toxicity due to multiple self-administered drugs; Michael Poole - ruptured berry aneurysm and consequences, bronchopneumonia; Grace Yates - acute bronchopneumonia following hypoxic-ischaemic encephalopathy caused by cardio-respiratory arrest post-ROD treatment

Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rapid Opioid Detoxification; Grace Yates (24, 2010) from hypoxic-ischaemic encephalopathy after ROD. All were unsuitable for offered treatments due to contraindications inadequately assessed. James's death not directly implant-related but would have benefited from methadone continuation; Michael's possibly preventable with proper post-discharge medical support and appropriate accommodation; Grace's preventable: proceeded with ROD despite ECG contraindications showing prolonged QTc, then received inadequate post-procedure monitoring. Critical clinical lessons: never use unapproved experimental treatments in vulnerable patients without robust protocols, proper informed consent, and comprehensive pre-treatment assessment documenting contraindications; maintain adequate staffing and continuous monitoring post-procedure; provide structured aftercare with medical supervision; ensure appropriate support on discharge.