Buried in a pauper's grave - verdict that ended years of distress - CNJ EXCLUSIVE

Published: 16 June 2011
EXCLUSIVE by JOSIE HINTON

A FAMILY’S battle for answers to a six-year mystery finally ended on Tuesday when a coroner ruled that a methadone prescription was to blame for the death of a man who was buried without his relatives even knowing.

Anthony Myers, 29, of Rochester Square, Camden Town, was found collapsed in his room while an inpatient at St Pancras Hospital in June 2005. He was buried in a municipal grave, often known as “pauper’s grave”, with five other coffins after health authorities decided next-of-kin could not be traced.

In order for Mr Myers to be reached for exhumation, two other bodies buried above him had also to be exhumed – those of Paul Startup, and Camden Town pensioner Fred Newman.

In fact, Mr Myers had three brothers and a sister who were not contacted at the time of his death. 

On Tuesday, relatives who had to fight to get their loved one exhumed heard at St Pancras Coroner’s Court that he had died from methadone poisoning.

Mr Myers, a former catering manager who had a young daughter, Brogan, had been living with his brother in Camden Town.

He had admitted himself to hospital six days before his death as a “cry for help” following a struggle with depression stemming from the death of his mother when he was 17 and his father a few years later.

An autopsy found he had been prescribed methadone by mental health professionals working for Camden and Islington NHS Foundation Trust.

After the hearing, his brothers spoke of the years of anguish they suffered after an administrative error meant they were not told about his death and he was buried in a “pauper’s grave”.

The family had reported him missing to police but it was only when the health trust carried out its own internal investigation some months later that its error was discovered.

By that time, Mr Myers had been buried beneath two bodies in one of the municipal graves at St Pancras Cemetery at East Finchley. The family had to embark on a two-year battle for access to his remains in a plot known only as Grave 179a.

The dead man’s brother, Thomas Myers, of Rochester Square, said this week: “Today we have got the result we were looking for but it has taken us six years to get to this point. Anthony and his family have been systematically let down by people paid to protect him. 

“He was misprescribed methadone which caused his death and we weren’t told he was in hospital or that he had died. He was buried in a pauper’s grave and we had to battle for two years to get him moved, which caused massive distress to the family and his daughter.”

The mother of the man buried in the grave above Mr Myers went through the same struggle to move her son’s remains.

Again, administrative errors led to Paul Startup being buried in the grave without relatives being informed.

He went missing after heading to London looking for work. When he died at the Royal Free Hospital in Hampstead in July 2005 after suffering from a blood clot, it was claimed his relatives could not be traced.

His mother, Millie Goodbourn, only found out that a man called Paul Startup had died because an NHS worker who knew the family saw his file. 

“I couldn’t believe it at first,” she said at the time. “I was shaking, crying. Why didn’t they let me know? I do miss him. He was a lovely boy.”

This week’s inquest heard that Mr Myers had voluntarily admitted himself to St Pancras Hospital after a “chaotic” period of his life which reached a peak on May 28, 2005 when he missed his niece’s wedding.

Although a heavy drinker, Mr Myers was not known to take drugs. While he was at St Pancras he gave conflicting accounts of his drug and alcohol use to mental health professionals. 

At one point, he claimed to have been taking three grammes of heroin a day for nine years, the inquest heard.

Doctors took his claims at “face value” and he was started on a course of methadone – the drug used as a substitute for heroin to help addicts. Urine test results later showed no evidence of drug use.

Dr Ian Prenelle, a consultant psychiatrist at St Pancras Hospital, told the inquest hearing: “At that time we didn’t have the drug-testing kits we have now. It was not uncommon then for lab tests to take several days to return to the ward by which time an opportunity would have been missed.” 

Mr Myers had taken four 20mg doses of methadone by the time he first collapsed on June 2.

Staff at St Pancras Hospital suspected he had taken an overdose but this theory was ruled out by University College Hospital A&E doctors as he was not showing any physical signs and appeared “well”.

Later that day he was given a further 20mg dose of methadone and discharged back to St Pancras Hospital.

The next morning a student doctor discovered Mr Myers unresponsive in his room. 

A toxicology report found he had a level of 0.26mg of methadone per litre of blood when he died. Although that is not a dangerously high level of the heroin substitute, it can be fatal for those not used to it.

Coroner Dr Andrew Reid quizzed UCH doctors over why Mr Myers’ methadone was not stopped if he was brought in suffering from the effects of a suspected overdose.

Dr Manolis Gavalas, a senior doctor at UCH, told the inquest: “He had categorically denied taking an overdose. 

“In the real world of emergency medicine where we see six patients in our coffee breaks we have to determine: is the patient sick, yes or no? If yes, how can we treat them and if no, how can we discharge them safely?

“This was a patient who came from another hospital within our trust with a drug chart. I would not expect my SHO [junior doctor] to discontinue medication prescribed by another professional.”

Recording a narrative verdict, coroner Dr Reid said Mr Myers died as a result of “misadventure partly because the nature and degree of his substance misuse history was not recognised”.

He added: “It appears Mr Myers’ reported history of drug use was ­taken at face value. An opportunity to recognise an adverse side-effect was unfortunately missed when he collapsed and was sent to A&E. 

“No definitive conclusions were reached and he was returned to the ward where his drug regime was never formally reviewed.”