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Fatal Accident Inquiry into the Death of David Clark, Sheriff Ian Dunbar, Dunfermline Sheriff Court, 29 May 2011


In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that David Clark (DOB 18.06.86) died at 37 Grainger Street, Lochgelly, Fife at approximately 1.19 am on 12th May 2007. In terms of s.6(1)(b), the cause of death was the adverse effects of heroin and methadone. A formal determination was made under s.6(1)(c).
David Clark was a heroin addict who, at the time of his death, smoked or injected around £40 worth of heroin per day. He was made subject to a Drug Treatment and Testing Order in April 2007 and placed on a Methadone programme. On the first day of his treatment, 10th May 2007, he was prescribed 80mgs of Methadone. The next day David was seen by the doctor and was given 100mgs of Methadone. Later that day he smoked and injected heroin with his flatmate Robert Palmer at their flat at 37 Grainger Street. In the evening David fell asleep on the sofa and was heard snoring. Later in the evening David's brother Ryan noticed that he had vomited and was not breathing. Ryan called for an ambulance and attempted resuscitation. Paramedics arrived and continued resuscitation without success.


In terms of s.6(1)(c) the sheriff found that only reasonable precaution whereby the death might have been avoided was if David Clark had not taken heroin after he had been prescribed and taken methadone. In addition, the sheriff noted three issues that should be addressed to improve services. First, the sheriff suggested that the pathology/toxicology services available in Dundee should be upgraded. Second, guidelines and protocols for methadone treatment should be better defined and staff made fully aware of them. Finally, improvements should be made in note-taking and communication between staff.