Marcus Dale Hamilton · Prevention of Future Deaths report

On 12th July 2017 I commenced an investigation into the death of one Marcus Dale Hamilton (“MDH”). The investigation concluded on the 27th October 2017.

The medical cause of death was;

1a) Drug toxicity

and the conclusion was;

Drug related

MDH was a long-term service user of the Trafford Drug Treatment Services, over 20 years. MDH’s death was caused by the combined respiratory depressive effects of a number of drugs taken in slight excess and at such levels that none of them alone would have given rise to a fatality. There was no evidence of deliberate intent.

For a number of years MDH was on a maintenance programme with MXL, which he received on a 28 days prescription.

In December 2015 MDH informed GMMH that he was taking a long trip of 51 days, to Goa, India. MDH was advised that he could only have a 28 day prescription of MXL to take with him. He was only given a 28 day prescription along with the necessary documentation for travelling with the drug.

In discussion with the witness from GMMH (MDH’s Recovery Worker) regarding the fact that MDH would clearly run out of his prescription maintenance MXL part way through his holiday the answer I received was that there were drugs in India and MDH would be able to obtain some more MXL. The witness accepted that it could not be certain that MDH (or any other service user) would be able to obtain their maintenance drug (MXL or other) and that such MXL that MDH managed to get hold of would probably have been from the illicit drug market. The same applying to any other service user for whatever maintenance drug.

Whilst I accept that what was said does not likely represent GMMH policy what the witness was telling me was, in fact, the reality of the situation created by GMMHs policy/protocol.