The founder of a private drug treatment clinic was today found guilty of inappropriately and irresponsibly treating several heroin addicts.
The General Medical Council (GMC) found that Dr Colin Brewer had prescribed several patients with a dangerous cocktail of potentially life- threatening drugs to wean them off their addictions.
One patient, Grant Smith, 29, choked to death on his own vomit in September 2001 after being signed up for a controversial DIY home detox kit containing 16 drugs.
Panel chairman Professor Denis McDevitt said: "The panel finds proved that Mr GS [Grant Smith] died as a result of aspiration of vomit by reason of the use by him of the drugs prescribed by you.
"The panel has found proved that your management of Mr GS was inappropriate and irresponsible and failed to take adequate care for his treatment needs and safety."
Dr Brewer, 63, who saw patients at the Stapleford Centre practices in Belgravia, London and Stapleford Tawney, in Essex, must now wait to see whether the GMC panel finds him guilty of serious professional misconduct and strikes him off the medical register.
Some of the patients, or their untrained carers, were left to use their own judgment to decide how much medicine should be taken because they were given bafflingly complex and confusing dosage and care instructions, the GMC heard.
Prof McDevitt said allowing Mr Smith's withdrawal to be managed by his mother at his Northampton home was not "a safe or suitable method of managing a patient who was being treated with large doses of potentially dangerous drugs".
He said: "The instruction sheet was complex, unclear, confusing and inadequate. The drugs listed on the sheet and their doses were not necessarily the same as those on the prescription.
"Instructions such as the right dose is 'enough' (ie enough to keep the patient reasonably comfortable or even a bit sleepy) may be difficult for an untrained carer to apply safely."
Mr Smith's mother had said she did not realise from reading the leaflet that she should be watching her son around the clock when he was sedated, even if he was asleep.
Dr Brewer was one of seven Stapleford Centre doctors based in Belgravia, London or Stapleford Tawney accused of serious professional misconduct in relation to 16 vulnerable patients.
The other accused doctors are Dr Tim Willocks, 47, of Stalybridge, Cheshire; Ronald Tover, 47, of Chesham, Bucks; Edinburgh-qualified Dr Hugh Kindness, 66, of Ashtead, Surrey; Dr Anthony Haines, 75, of Vitrac St Vincent, France; and Dr Nicolette Mervitz, 30, of Johannesburg, South Africa.
Dr Martin O'Rawe, 46, of North Kensington, London, was cleared today of serious professional misconduct.
Prof McDevitt also highlighted failings in Dr Brewer's treatment of a woman identified only as AS between August 1997 and March 2003. The amount of methadone he prescribed her between August 1997 and September 1999 had been inappropriate and irresponsible, he said.
The panel added that Dr Brewer should have been wary that her drugs might have been sold on because she was impoverished and living with a known drug user.
