The drug is derived from the roots of a rainforest shrub and typically used in western Africa to combat fatigue, hunger and thirst. In low doses it is a stimulant, in high doses a hallucinogen. No clinical trials of the drug have been undertaken and it has been linked to sudden cardiac death following ingestion.
Dr van Dorp told the commissioner he had treated approximately 54 clients with the drug since 2011, with no adverse outcomes. Ms Palmieri-Chuck was administered six doses of the drug over 24 hours. Dr van Dorp left to go overseas only five hours after her last dose. Ms Palmieri-Chuck was then in the care of Mrs van Dorp, referred to as the "iboga assistant", who had no medical training.
She visually checked on Ms Palmieri-Chuck at least five times over the next 15 hours before discovering her dead at 6am the following day. Ms Palmieri-Chuck had not moved since 3pm the day before when Mrs van Dorp recorded her to be "lying still. Arm raised over head."
After finding the body, Mrs van Dorp immediately called her husband, then 111, though Mr Hill said her focus should have been on providing CPR even though the patient had probably been dead for some time.
In the report, Mr Hill found both Dr van Dorp and Mrs van Dorp failed to monitor their patient adequately, breaching the patient's rights.
"In my view, [Mrs van Dorp's] monitoring of [Ms Palmieri-Chuck] was insufficient and should have included (as a minimum) checking her breathing and pulse at each check." Because the medicine was experimental, Dr van Dorp should have acted in a "more cautionary manner". His monitoring of the patient was "regrettably lax", the report said.
Mr Hill found the consent form - which was not signed by Mrs Palmieri-Chuck - to be misleading as it implied death was only possible with the interaction of other drugs.
He found Dr van Dorp breached the patient's rights by failing to provide the patient with adequate information about the risks and side effects of ibogaine, or about the experimental nature of its use to treat drug addiction. Iboga New Zealand, the company that ran the facility and was owned by the van Dorps, breached the patient's rights and did not operate safely.
"The lack of comprehensive protocols and failure to comply with what protocols were in place give the overwhelming impression that it was a sloppy operation with little regard for professional standards," Mr Hill said.
Dr van Dorp does not hold a current practising medical certificate. Mr Hill recommended that the Medical Council undertake a competence review if he did reapply.
The matter was now before the coroner, who would determine the cause of death.
The HDC report was conducted after a complaint, with a copy of the investigation going to the coroner, who can make recommendations.
A copy was also provided to Northland District Health Board, Addiction Practitioners' Association Aotearoa-New Zealand and Police, among others.
Ms Palmieri-Chuck's husband, Peter Palmieri-Clark, declined to comment on the HDC decision yesterday.
In 2012 the van Dorps told the Northern Advocate that the"miracle" drug allowed fora relatively painless detoxification.
