Apologies to all readers outside of Britain who may never have heard about The Pirates of Penzance, definitely not The Pirates of the Caribbean. PoP though has a famous song – I am the Very Model of a Modern Major General – featuring a dimwit General who knows everything about everything except military strategy.
This post ideally needs an I-am-the-Very-Model-of-a-Modern-Medical-Doctor rap.
“I fall asleep reciting the text of drug labels
And sing Guidelines in the bath
When I learn to keep you safe on a medicine
or know what to do if things go wrong.
You’ll say there never was a better Medical Doctor”
Nicky Naunton Morgan
In early 2024, after a few nights poor sleep, his doctor, Nicky Naunton Morgan put Tom Kingston on zopiclone. This hypnotic can help some to fall asleep quickly but at a cost of waking up a few hours later with rebound insomnia. Rebound means you are not just waking up and could drift off again at any moment. It means you are unlikely to get back to sleep without another tablet which will leave you hung-over the next morning.
It also comes with rebound anxiety. This appears to have happened Tom.
Nicky Naunton Morgan is a good doctor. Checking in with her, Tom said he was more anxious than before. She laid out some drug and non-drug options. They opted to add sertraline in a 50 mg dose to his zopiclone. A week later he was back in touch considerably more anxious. Convinced sertraline had made things worse, he had stopped it after 4 days.
They discussed options. She replaced zopiclone with a low dose of diazepam and sertraline with citalopram – an identical medicine. He only took two doses of this.
Tom took his own life 10 days later.
An inquest on his death took place in early December, at which there was no evidence that anything other than Tom Kingston’s SSRI intake likely caused his death.
Dr Naunton Morgan was not present. Her report did not point to anything else. Her Medical Protection Society lawyers, who were present, did not point to anything else. If Dr. Morgan thought, as an initially skeptical coroner concluded, that Tom’s SSRIs had likely killed him, did she have a fiduciary duty to him and his family to say so?
Do insurance lawyers have a fiduciary duty to support good medical practice rather than just save a doctors skin? Is their advice to doctors not to implicate a prescription drug in a death a breach of this duty? See an advert for Medical Insurance in Probity Blockers and Trans Medicine.
The Coroner has submitted a Preventing Future Deaths report to the British medicines regulator (MHRA) suggesting the wording on the drug label and in guidelines needs to state more explicitly that these medicines can cause someone to take their own life. See Guardian and See Times. On receipt of a report like this, regulators have a track record of asking – What did the treating doctor say? When the treating doctor has not blamed the drug, the regulator appears to think their hands are tied – Aunts, Ants and Regulators.
When it comes to warnings and clarifying communications, regulators primarily respond to pharmaceutical companies. But in this case, Lord David Alton, the British equivalent to a Senator, figures it is time to get MHRA to buck up their act and political input might help bring that about. Let’s see.
Richard Adams
In January of 2020, 25 year old Samuel Morgan, the eldest of Tania and Ian Morgan’s two sons, approached his doctor, Richard Adams, asking for an SSRI. Dr. Adams was reluctant to prescribe. Sam was fit and healthy, a stellar academic student, good at sport, and settled in a happy relationship. He was nervous about whether the forthcoming results of his course work would meet his very high expectations. He persuaded Dr Adams to prescribe citalopram.
A week later he hung himself. His searches on his computer in the preceding days suggest he thought he was going mad. He came top of his class posthumously.
Neither Dr Adams, when he met Sam’s bewildered family, nor the medical record point to anything other than the drug as the cause.
I was retained by the family. I emailed Dr. Adams offering to outline the trials done in the 1980s near where he worked that had shown healthy volunteers becoming suicidal on an SSRI and taking their own lives and other evidence about SSRIs he was unlikely to know about.
I indicated neither he nor his colleagues needed to say a word to me – simply listen. That he could be the most helpful person for the family. In the unlikely event the family wanted to take an action against him, he could count on me to be an expert on his behalf.
He responded that his lawyers had advised him not to speak to me.
At the inquest, his lawyer spoke for him blaming the illness. The Coroner filed a Preventing Future Death report. The regulator asked what the treating doctor had said. Briefed on this, the regulator did nothing.
Eluned Morgan, then the Minister for Health in Wales, said the regulator had not advised any action and that she had every confidence in MHRA, a wonderful regulator, and in the guidance from Britain NICE Guidelines apparatus. So much for politicians being able to influence the bureaucratic apparatus.
Eluned Morgan, now Wales’ First Minister, MHRA, the chief coroner, the Medical Protection Society and Medical Defense Union were all briefed on the role that medical insurance lawyers have played in this and other cases. Neither Ms. Morgan, MHRA, the chief coroner, nor any insurer have responded on this point. See Morgan v Morgan and the Future of the NHS
Richard Adams appears to have retired shortly afterwards. I can find no trace of him or photo of him – hence the Avatar above.
Ronan Brannigan
O’Neill is one of the most famous Northern Irish names. In 2011, Stephen O’Neill, grieving the death of his father, was given fluoxetine. It agitated him and he stopped it. His medical record noted an adverse event on treatment.
In 2016, Stephen attended his doctor, Ronan Brannigan with a chest infection who gave him doxycycline, a serotonin reuptake inhibiting antibiotic, that can cause agitation and suicide. A few weeks later, having stopped doxycycline, Stephen returned agitated.
Missing the role of doxycycline, Dr Brannigan put Stephen’s agitation down to a former partner’s forthcoming marriage to someone else. Stephen didn’t think so. Dr Brannigan started Stephen on a beta-blocker. When the problem did not settle, he prescribed sertraline.
Stephen had an immediate catastrophic reaction to this. He checked with a pharmacist who agreed that sertraline was the likely cause.
The problem was bad enough for Stephen to get himself admitted to hospital. The admission record notes an adverse response to sertraline. He was initially started on a low dose of diazepam, a treatment companies recommend to manage these problems. It helped but was stopped 2 days later and he was put on an antipsychotic, followed by other drugs all of which risked making SSRI induced agitation worse.
Stephen made it clear these did not suit him while diazepam had helped. He was not listened to. The other options increased his agitation through to his death by hanging.
Dr Brannigan was at the inquest and spoke before me. Perhaps surprised to have a doctor speaking for himself, the coroner, Patrick McGurgan seemed to me in rather odd fashion to go out of his way to praise Dr Brannigan’s report to the skies and to support him in his testimony. Having said this, Dr Brannigan did seem like a decent man caught in headlights of some sort, when he almost didn’t need to be – the hospital services had badly compounded any initial errors.
Dr Brannigan said that he had put Stephen on sertraline because on that day he seemed a completely different man and sertraline was the best treatment for severe depression – strongly implying he saw Stephen as severely depressed and that his severe depression had killed him.
There were two odd aspects to this. Stephen’s brother-in-law had driven him to and picked him up from the clinic that day and thought he seemed mildly anxious, no different to the previous few days.
The idea that sertraline is the best treatment for severe depression is ludicrous. Pfizer had great difficulties getting sertraline licensed for depression – in the end getting it through FDA without meeting the approval criterion of two positive placebo-controlled trials. It had failed completely in severe depression.
I introduced the coroner to the difficult situation he and I and all of us were in. The literature on sertraline was ghostwritten. Pfizer had run a healthy volunteer trial where all volunteers put on sertraline had reactions like Stephen’s and had dropped out of the trial within 4 days. Pfizer concluded sertraline caused these reactions.
MHRA didn’t get to see the sertraline trial data. Sertraline got a British license after some shenanigans from one of their medical experts, who kept his links to Pfizer quiet. Over a decade after licensing, MHRA had to be told by me about the existence of the healthy volunteer trial where the subjects had all reacted the same way as Stephen.
Dr Brannigan’s initial statement in the case was weak and withdrawn. It was replaced by something that looked like it was written by a lawyer. His medical insurance lawyer was at the inquest and during my testimony was leaping up and down and from foot to foot. He launched into an aggressive attempt to question me. He lost the run of himself and I had to ask him to introduce himself before I’d answer anything.
The coroner suggested I get in writing all the points about ghostwriting and that NICE guidance on sertraline and related drugs were based on ghostwritten articles etc. In the following weeks, I did this, forwarded the material to him, and later ran the correspondence as blog posts. Some key posts are From Stephen O’Neill to the Crack of Doom, The NICE before Xmas with video presentations here The Death of Stephen O’Neill and You , The Perfect Killing Machine and Escape from a Prescription Drug Maze
The response from the then Northern Ireland Minister for Health, Robin Swann, was that he had not been advised by the marvelous MHRA or wonderful NICE guideline apparatus that there was any need to change anything. A response almost word for word the same as Eluned Morgan.
Michelle O’Neill, formerly Stephen’s sister-in-law, is now Northern Ireland’s First Minister. She too seems powerless to do anything or perhaps her party Sinn Fein has close links to the pharmaceutical industry that she does not want to disrupt, or perhaps this is beyond the remit of devolved administrations and is a matter for Britain’s Federal Government.
After the inquest, Dr Brannigan moved jobs and out of the area.
Richard Smith
Richard Smith began as a medical doctor and spent several years in clinical practice before becoming editor of the BMJ. As far as I know, Dr Smith hasn’t prescribed an antidepressant that caused anyone to take their own life. But tens of thousands of people have had deaths by their own hands induced by an antidepressant as a disastrous unintended consequence of his decision to publish a pharmaceutical company article in BMJ.
In 1990, a series of articles by distinguished medical academics in some of the best journals outlined Prozac (fluoxetine) induced suicidal thinking and acts. By all canons of scientific and medical causality, these articles proved beyond reasonable doubt that Prozac had the capacity to cause suicide.
In response, Eli Lilly, the makers of Prozac claimed to have meta-analyzed what they called their Randomized Controlled Trial (RCT) data, and the result did not show Prozac causing suicide. Lilly pitched their article as the science of cause and effect and the reports of 30, 40 or more cases as anecdotes. They invited doctors, the public and scientists generally to choose between the science and the anecdotes.
After the article was rejected by one journal, Lilly approached BMJ. The BMJ reviewer said it was not correct to say the data exonerated Prozac from causing people to commit suicide. There were more suicidal events on Prozac than on placebo. Lilly argued the difference was not statistically significant and therefore there was no excess of events on Prozac.
Had the reviewer and Dr Smith read the small print properly, they would have seen the data showed a statistically significant excess of suicidal events on Prozac. Dr Smith opted to publish, a version of the paper that retained wording suggesting there was no evidence Prozac could possibly make anyone suicidal.
Why did he opt to do this? Perhaps he was rubbed up the wrong way by a medical grandee at some point in his clinical life and figured this first glimpse of Evidence Based Medicine was a way to take down Eminence Based Medicine. This was a line that young EBM enthusiasts who emerged shortly afterwards, gleefully almost, claimed.
Dr. Smith seems to have thought that Lilly’s article had the appearances of a pharmaceutical company attempting to do science and more of the same should be encouraged. A valid point perhaps if he had ensured the claims in the article were in line with the data.
This was before anyone recognized that companies don’t do trials, they do assays designed to get licenses. That the patients in their assays may not exist. That they use all kinds of coding tricks, words like emotional lability, and other maneuvers as Lilly showed in this article by adding a suicidal event to the placebo arm that didn’t happen on placebo.
The article was published on the day in September 1991 when FDA were holding a hearing on whether Prozac should carry suicide warnings and was likely influential in FDA deciding not to issue warnings despite these very sad but essentially anecdotal cases.
Lilly’s article – and not Gordon Guyatt or the Cochrane Collaboration a year later – created Evidence Based Medicine (EBM). A later medical academic glove slipped over the iron fist of company EBM. This move would have gotten nowhere if companies ever figured EBM was likely to rein them in. But in 1991, Lilly showed the rest of the industry that EBM could be the gift that kept on giving.
This Lilly BMJ article caused doctors like Drs Morgan, Adams and Brannigan to lose confidence in their own and their patients’ judgement calls about what was happening on a drug and to figure that practicing according to a drug label is practicing EBM. Lilly were certainly in the business of helping them think this way. Until they and FDA put a public relations fuss, as FDA at one point called it, to rest, if any doctor got sued for claims of a possible Prozac induced suicide, Lilly offered to cover their legal defence.
In 1999, I was an expert witness in the Forsyth trial, a Prozac induced suicide and homicide case. This put a tranche of Lilly documents in the public domain, showing Lilly personnel concerned about their cover-up efforts. I called into BMJ to see Dr. Smith personally bringing a set of document summaries and a draft of a Failure to Warn article about what they showed.
Dr Smith wasn’t there but I left the material with Jane Smith and had a Smith email soon after suggesting that given BMJ’s role in creating this story they probably should run my article and it was being sent out for review.
It was sent to John Geddes, who totally misread, or was asked to misread what he was sent, or was sent the draft article without the document summaries that the article was designed to explain. This was 8 years after the original Lilly article and by this stage EBM was in full flow. There were a lot of medical zealots who only wanted to see RCT data about whether we are likely to take our next breath or not rather than believe it was common sense to know we were. So perhaps he did see Lilly documents saying our drug causes suicide but was not inclined to concede that these were evidence that Prozac caused suicide. Without being able to put his hand in the wound where the data was, he was opting to be a Doubting John.
I offered to run a data based piece for BMJ but the surprising response from Dr Smith was BMJ will ‘never publish anything you send us’.
A few years later, on leaving BMJ, Dr Smith began writing articles and a book about pharmaceutical companies laundering their dirty linen through medical journals. At the same time he was acting as a reviewer for BMJ advising against publishing articles, for instance, on the obvious problems with Study 329.
In multiple blog posts and through other contacts since, I’ve suggested to Dr Smith that this is not all past tense. What he did in 1991 has caused problems to thousands of individuals, to the medical profession in general, and in particular to an exponentially escalating number of young people. His Lilly article was the stone that dislodged an avalanche. A statement recognizing that despite good intentions he made a bad mistake in 1991 could even now do a lot of good.
In all his writings about how awful pharma are, he has not that I am aware of made even a token gesture toward recognizing the mistake.
Dr. Smith is still a medically qualified doctor. Everyone involved in prescription drugs, especially doctors, has a duty of care to and some responsibility for a person who in taking a prescription drug is forced to give up natural caution, their best defense, and accept what someone else decides for them.
Pharma endlessly up front and in lurid language tell the lay and medical media that they need to act responsibly, by which companies mean support the company line, or else they are likely to have blood on their hands.
Out, out damned spot
Ian Hudson
Dr. Ian Hudson, another medically qualified British doctor, worked as a pediatrician before making a switch to GlaxoSmithKline (GSK), where he became Chief Safety Officer.
As a Safety Officer. Dr Hudson has to have known about the excess of suicidal events on paroxetine in GSK’s adult trials, and about company breaches of FDA regulations to hide this excess. But Dr Hudson testified under oath in 2001 in the Tobin v GSK lawsuit that GSK adheres to EBM and EBM methods showed there were no adverse events that could be linked to paroxetine – not just no suicidal or homicidal events.
Did Dr Hudson lie under oath in the Tobin trial? A jury of plain folk from Wyoming must have thought he was either lying or mad and returned a verdict against GSK.
Dr. Hudson at this point has to have known or should have made it his business to know all about Study 329, GSK’s flagship licensing assay aimed at getting FDA approval for the company to claim paroxetine was an effective and safe antidepressant for adolescents. Study 329 finished in 1998, had a statistically significant excess of suicidal events on paroxetine compared to placebo. The same pattern of lack of efficacy and an excess of harms held true for GSK’s other studies in this age group.
A few years later, Dr Hudson joined Britain’s medicines’ regulator, MHRA, just as the fuss about adolescent depression trials blew up. In terms of promoting patient safety, he was ideally placed within the regulatory apparatus to know what the problems were across all antidepressants and to know that when regulators asked companies for all their trials there were tricks companies, including GSK, were using to avoid handing over all studies. He likely knew what was in the studies they weren’t handing over. He was also ideally placed to ensure company safety.
During this period, Dr Alastair Benbow was the lead for psychiatry and later European Chief Medical Officer for GSK. He appeared on several Panorama programs about suicidality and dependence on paroxetine and either lied through his teeth or doesn’t understand medical data very well. What he was saying to the entire UK public was there was no problem on paroxetine, when at the same time he was the notional author on GSK documents to FDA and MHRA showing a significant excess of suicidal acts on paroxetine compared to placebo in Study 329. This made a 2001 GSK published article on Study 329 fraudulent – if that is anyone could find an internal GSK document showing GSK knew this. Almost immediately after Dr Benbow’s Panorama interview, just such a document turned up.
Dr. Benbow was referred to Britain’s registration body for doctors, the General Medical Council (GMC) – see Deciphering the Web We Have Woven GMC were asked to investigate his dangerous opinions at odds with the facts. As most readers could predict even if not alerted by the comments after last week’s post, GMC declined to get involved, as they would have declined to get involved in a similar request about Drs. Hudson or Smith.
Had GMC got involved in cases against Drs. Morgan or Adams, I would gladly have helped both of these doctors.
First Do Admit no Harm
The framework that is causing all these problems was put in place in 1962 following the thalidomide crisis. Politicians and academic medical doctors created it. Doctors were supposed to be a key component of the wider regulatory system. Companies write drug labels that bureaucrats (FDA, MHRA, EMA) look over. But other doctors paid heed to what doctors were writing in medical journals about hazards.
Articles like this were labels that other doctors were more likely to take seriously than company labels. Next week RxISK will post a Medically Informed SSRI label.
Lilly’s article in the BMJ put an end to all this. Good doctors now think practicing Evidence Based Medicine means practicing according to drug labels and keeping to NICE guidelines which are based on ghostwritten representations of company assays.
Medical journals like BMJ and NEJM and medical academics are too scared to say boo about these ghost-written articles for fear of a libel suit. They run articles denouncing fly-by-night Predatory Journals that are taking money from them – but our supposedly very best medical journals have become Zombie Journals.
There was a temptation to call this post – The Good Doctor – a title that echoes The Good German. The German version suggests quiet Germans knew what was going on but stayed quiet. Few doctors have much grasp of what has been going on out of their sight. It is going to take leadership to get us out of this mess. All of the doctors listed above are in a very good position to offer leadership that the system will find difficult to ignore. It might even help make medicine great again.
annie says
This Post is a thrilling read, puts everything in context and illuminates how the mighty have fallen in and how we can get to MMGA. Every doctor mentioned is either a coward, downright lazy, cowering behind lawyers, and unable to face up to possible ‘blood on their hands’
Dr. Richard Smith seemingly blew with the wind.
Dr. Ian Hudson, we have seem him testify, had an almost casual approach to in his very odd and strange testimonies. Working for GSK, maybe this type of approach was catching. He seemed to me to be a very peculiar choice to head up the MHRA. His ‘Missing in Action’ episode for a Government Inquiry in to Seroxat was a complete joke. The MHRA figures trying to cover for him was laughable in the extreme. But that all came to nothing and he wasn’t forced to attend.
Look at what they have done. No heroes here. And because of all this, people have been immeasurably harmed. Some have died harrowing and horrific deaths, violently. No salvation for them.
The Killing Machine will continue until they all get a handle on it, but we know where they buried the bodies.
The Thomas Kingston Affair has been covered in all the major media. If all those mentioned, had held their head’s high, he would still be here today. But so many have gone before him. We can all probably think, who would have thought it would happen to him. But anyone out there today, could be plucked at random, here today, gone tomorrow.
Thanks for a really great post. It should provoke a great response.
There’s Something in the Air
Call out the instigators
Because there’s something in the air
We got to get together sooner or later
Because the revolution’s here
And you know it’s right
And you know that it’s right
We have got to get it together
We have got to get it together now
Lock up the streets and houses
Because there’s something in the air
We got to get together sooner or later
Because the revolution’s here
And you know it’s right
And you know that it’s right
We have got to get it together
We have got to get it together now
Hand out the arms and ammo
We’re gonna blast our way through here
We got to get together sooner or later
Because the revolution’s here
And you know it’s right
And you know that it’s right
We have got to get it together
We have got to get it together now – Thunderclap Newman
Dr Pedro says
Here is the MHRA’s response to the Coroner’s Reg 28 report concerning Samuel Morgan’s suicide.
https://www.judiciary.uk/wp-content/uploads/2021/01/2020-0276-Response-from-MHRA-Redacted.pdf
Expect cut and paste
David T Healy says
Follow up from Dr Pedro
24th November 2022 FOI 22/1065
Dear
Thank you for your Freedom of Information (FOI) requests dated 27th October 2022 where you requested the following:
Upon receipt of fatal COVID-19 AstraZeneca Vaccine reports can the MHRA request inquests into the cause of death? If yes, how many times has this happened?
The percentage of Yellow Card reports that are the subject of Coroners inquests?
How many Regulation 28, Report To prevent Further Deaths notifications have the MHRA received which included reference to the COVID-19 AstraZeneca vaccine?
Does the MHRA, upon receipt of a Regulation 28 notification in respect of COVID-19 AstraZeneca forward it /inform the manufacturer?
Does the MHRA provide responses within the 56-day deadline contained in the Regulation 28 notification and if so, are these published/accessible to the public?
The MHRA continuously monitors the post-marketing safety of vaccines through a variety of pharmacovigilance processes. All adverse reaction reports submitted by patients and healthcare professionals via the Yellow Card scheme or by pharmaceutical companies, are reviewed by our signal assessors to ensure all information provided by the reporter is accurately committed onto our database. Any relevant or missing information is quickly, and adequately followed-up with the reporter to obtain the full picture of the individuals medical history.
We follow-up all fatalities, where permission has been provided to do so, for further information, including post-mortem details if available. All details within a report are thoroughly assessed to consider whether the suspect drug or vaccine may have caused the event, or whether the event and fatal outcome were likely to be purely coincidental and due to underlying illness. Further to point 1 requested above, we cannot confirm the causality of the fatal event as this can only be determined by the coroner. It is also not within our remit to request an inquest into a particular fatality.
Regarding point 2 of your request as to the percentage of Yellow Card reports subject to coroner’s inquest; this is not a detail that the MHRA specifically requests and therefore cannot provide this. We encourage all patients and healthcare professionals to reports to the scheme, including coroners. However, I can confirm that we have received 34 fatal adverse reaction reports for all COVID-19 vaccines reported specifically by coroners.
Further to points 3 to 5 of your request, I can confirm that the MHRA have not received any Regulation 28 reports for any COVID-19 vaccine. The MHRA do respond to Regulation 28 notifications and the responses are published here: Reports to Prevent Future Deaths – Courts and Tribunals Judiciary. The MHRA may request a time extension from the coroner in order to fully investigate and seek expert advice from the appropriate expert advisory committee of the Commission on Human Medicines if required.
Additionally, the MHRA has a responsibility to inform pharmaceutical companies of any adverse reaction reports received by the MHRA, for medicines and vaccines that they hold a license for. The MHRA forwards on anonymised Yellow Card report details for Regulation 28 notifications, the same as it does for all other Yellow Card reports, this is covered in our privacy policy.
If you are dissatisfied with the handling of your request, you have the right to ask for an internal review. Internal review requests should be submitted within two months of the date of this response; and can be addressed to this email address.
Yours sincerely,
FOI Team,
Vigilance and Risk Management of Medicines Division
Dr. David Healy says
The worry with all this is the MHRA will be seen as blocking the way. These Covid death reports were all likely filed without a doctor saying there is no other way to explain this death besides the vaccine. Without input like this, MHRA are left shuffling deck-chairs
D
chris says
“after a few nights poor sleep,”
Sleep can’t be forced with drugs nor thoughts. If anyone reading this is having insomnia watch this, you do not need to spend any money it’s all here:
https://m.youtube.com/watch?v=Gyylk1LjPHA
Treating sleep anxiety insomnia via a GP is the entering wedge to psych hell.
“Almost immediately after Dr Benbow’s Panorama interview, just such a document turned up.”
The story can be found here
https://study329.org/
and the book: Children of the Cure
It’s just incredible.
“Had the reviewer and Dr Smith read the small print properly, they would have seen the data showed a statistically significant excess of suicidal events on Prozac.”
This is for Dr Smith
https://m.youtube.com/watch?v=9Eet4x5_8tE
Dr. David Healy says
A follow-up follow-up from Dr Pedro
https://yellowcard.mhra.gov.uk/how-to-report
interesting video
Dr P
Anon says
To make life a bit easier if wanting to make a Freedom of Information Request
Anybody can register and use this for free:-
‘What Do They Know’
Bear in mind names will be made public, the names of the bodies/orgs being contacted for FOI are public and are free to look up on the web site. , times lines of responses are made public. W D T K make suggestions about following up in the event of procrastination or fobbing off.
Anon says
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Minister of State for Mental Health, Suicide Prevention and Patient
Safety
Nadine Dorries MP
House of Commons
London
2. Chief Executive, MHRA
1 CORONER
I am Colin Phillips, acting senior coroner, for the coroner area of Swansea and Neath
Port Talbot
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
[HYPERLINKS]
3 INVESTIGATION and INQUEST
On 29 January 2020 I commenced an investigation into the death of Samuel David
Morgan aged 25. The investigation concluded at the end of the inquest on 1 December
2020. The conclusion of the inquest was Suicide with Narrative.
4 CIRCUMSTANCES OF THE DEATH
The deceased was Samuel David Morgan (“Sam”) and he died on the 16th January 2020
at his home ..in Swansea as a consequence of selfsuspension. The risk of Sam taking his own life had not been identified. On the 9th
January 2020 he had been prescribed a 14 day course of 10 mg citalopram antidepressants. A review assessment was not set at the time of the medicine being
prescribed in contravention of NICE Guidance.
5 CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
Sam’s mother saw a change in his mood the 7 days before his death which she
attributes to the effect of SSRIs. Whilst the precise effect of this medication (Citalopram)
on Sam is unknown, it is clear that Sam had never self-harmed previously and his
actions were completely out of character. He had started researching schizophrenia on
his phone just before his death. Every medicine pack includes a patient information
leaflet (PIL), which provides information on using the medicine safely and allows patients
to read at their leisure. However, it has been suggested that the “Black Box Warning” (as
developed by the Food and Drug Administration in the USA) would have a more
2
immediate impact and capture some patient’s attention highlighting any risks. The
simple and clear message in this specific case would be that there is an increased risk
of suicidal thinking in young adults. The benefits of such simple and direct messaging
extends to all prescribed medicines and associated major risks.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and/or
your organisation have the power to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 3 February 2020. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons (Parents)
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.
9 9.12.20
SIGNED BY CORONER HomePrevention of Future Death Reports
May 19, 2023
Samuel Morgan: Prevention of future deaths report
Suicide (from 2015)
Then this
Date of report: 18/05/2023
Ref: 2023-0163
Deceased name: Samuel Morgan
Coroner name: Kirsten Heaven
Coroner Area: Swansea Neath Port Talbot
Category: Suicide (from 2015)
This report is being sent to: Swansea Bay University Health Board
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive of Swansea Bay University Health Board (Mark Hackett),
1 CORONER
I am Kirsten Heaven, Assistant Coroner, for the coroner area of SWANSEA NEATH & PORT TALBOT
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3 INVESTIGATION and INQUEST
On 13th May 2019 an investigation was commenced into the death of Samuel Alexander Morgan who was found deceased in his parents’ house on the 9th May 2019 after having tied a ligature around his neck. He was 29 years of age at the time of his death. The investigation concluded at the end of the inquest on 6th March 2023.
The medical cause of death was:
1a Hanging
4 CIRCUMSTANCES OF THE DEATH
The deceased was Samuel Alexander Morgan. At the time of his death Samuel was suffering from alcohol addiction and had a diagnosis of ADHD and social anxiety. Prior to his death Samuel had received treatment from the Community Drug and Alcohol Treatment (‘CDAT’) team and primary mental health services. Samuel was discharged from CDAT fifteen months prior to his death. CDAT had information on their system (including from their own risk assessment) to indicate that Samuel had been assessed as a significant risk of suicide. There was other valuable information about Samuel’s risk factors on the CDAT system. At the time when Samuel was under CDAT the GP had also referred Samuel to the community mental health team raising his concerns about Samuel’s risk of suicide. It is not clear is CDAT had access to this letter. When the primary mental health services consultant began treating Samuel for his ADHD – which continued up to Samuel’s death – he received a referral from CDAT but he did not have access to the detailed information on the CDAT electronic system. The consultant could not and did not see the CDAT risk assessment, the outcome and assessment from the individual CDAT sessions and other vital historical information of potential relevance to Samuel’s risk factors and triggers for suicide.
5 CORONER’S CONCERNS
During the inquest the evidence revealed matters giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
The first MATTERS OF CONCERN is as follows:
I am concerned that in cases where an individual is receiving treatment from alcohol and drug addiction services and treatment from the primary community mental health team that neither team is able to access the other teams records electronically. The lack of integrated electronic records between treating team means that important information regarding patient safety is not easily accessible between treating teams. Treating teams are reliant on referral letters which are necessarily limited and not always sufficient to capture all the detailed information available to a referring team. This is particularly concerning where there is dual diagnosis – such as substance misuse and mental health – given these are often complex cases. This is particularly the case where complex cases have not been referred into secondary mental health services and so do not have access to a care-coordinator who can oversee and understand the views of the various professionals treating and assisting an individual.
I am concerned that the lack of such an integrated electronic system of medical and treatment records inhibits the effective sharing of information regarding patient safety and so increases the risk that information of significance regarding a risk to life will be lost between agencies and not sufficiently understood between all those managing.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 July 2023. I, as the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Swansea Bay University Health Board and Samuel’s family.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9 18 May 2023
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Response from Swansea Bay University Health Board
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Swansea Bay University Health Board Headquarters
Dyddiad / Date: 12th July 2023
Ms Kirsten Heaven,
Assistant Coroner – Swansea and Neath Port Talbot,
The Guidhall,
Swansea,
SA1 4PE.
Dear Ms Heaven,
RE: REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
I write in response to the matter of concern raised in respect of the deceased Mr Samuel
Morgan.
The Health Board fully acknowledges the concerns you have raised and understands the
importance of sharing information between the Community Mental Health Teams (CMHT)
and the Community Drug and Alcohol Team (COAT) to improve patient safety and
outcomes.
The solution to this is intended to be the implementation of the Welsh Community Care
Information System, (WCCIS) which is a national IT programme aimed at enabling the safe
sharing of information between health and social care. This has been partially rolled out
within the Health Board as part of the implementation of the solution within Swansea Local
Authority. Further roll out within the Health Board is currently on hold pending the approval
by Welsh Government of recommendations made within a Ministerial Advice Paper
presented by the National Programme Team. The situation is complicated by the fact that
only one of our Local Authority partners has chosen to implement WCCIS. The current
deployment of the solution within SBUHB is managed by Swansea Local Authority who
. Any amendments to system functionality have to be
requested and implemented by the Local Authority.
The Health Board recognises the need to take urgent action to address the issues that have
been identified and understands that this cannot wait for the further development/roll out of
WCCIS. The following actions will therefore be taken:
1. For Swansea based teams there is opportunity to share information between community
mental health teams and drug and alcohol services via WCCIS which will allow 2 way sharing
of all information in the WCCIS system relating to episodes of care both within community
mental health services and drug and alcohol services. The technical changes to enable this
will be completed within 10 working days and it is intended that this will be implemented week
commencing 7th August 2023.
2. For NPT based teams and LPMHSS the Health Board will extend access to WCCIS on a
read only basis supported by a Standard Operating Protocol (SOP) for staff which requires
them to search WCCIS for episodes of care when patients enter and move through the
service. Staff will also be able to upload clinical records to the system which will enable
information sharing with other community based services. It is intended that this will be
implemented as from Monday 4th September 2023.
I am confident that the changes described above address your concern, however please
do not hesitate to contact me if you require any further information
Yours sincerely
CHIEF EXECUTIVE
Anon says
Coroner questions advice on risk of suicide with SSRIs after death of financier
BMJ 2025; 388 doi: https://doi.org/10.1136/bmj.r67 (Published 13 January 2025)
A coroner has questioned whether enough information is provided about the risk of suicide associated with selective serotonin reuptake inhibitors (SSRIs) after the son in law of Prince and Princess Michael of Kent shot himself after taking the antidepressant drugs.
Thomas Kingston, 45, died of a self-inflicted shotgun wound to the head last February while visiting his parents in Kemble, Gloucestershire.
Katy Skerrett, senior coroner for Gloucestershire, has sent a regulation 28 report, intended to prevent future deaths, to the National Institute for Health and Care Excellence (NICE), the Medicines and Healthcare Products Regulatory …
chris says
“As far as I know, Dr Smith hasn’t prescribed an antidepressant that caused anyone to take their own life. But tens of thousands of people have had deaths by their own hands induced by an antidepressant as a disastrous unintended consequence of his decision to publish a pharmaceutical company article in BMJ.”
“Dr Smith opted to publish, a version of the paper that retained wording suggesting there was no evidence Prozac could possibly make anyone suicidal.”
The BMJ also need to discuss the above and let’s invite Dr Richard Smith Chairman of ‘Patients Know Best’ to have his say.
Dr. David Healy says
Chris
This is a great idea. Richard – as someone I know says – has many personas.
D
Anon says
Medicines & Healthcare products
Regulatory Agency
10 South Colonnade
Canary Wharf
London
E14 4PU
United Kingdom
+44 (0) 20 3080 6000
gov.uk/mhra
Dear Mr Phillips,
Inquest into the death of Samuel David Morgan
Thank you for your email dated 9 December enclosing the Regulation 28 report to prevent future deaths
relating to the tragic death of Mr Samuel David Morgan, aged 25 years, by self-suspension 7 days after
being prescribed 10mg citalopram. I extend my sincere condolences to Mr and Mrs Morgan and the family
and friends of the deceased.
Citalopram is an antidepressant that belongs to the selective serotonin reuptake inhibitor (SSRI) class of
medicines. The current warnings about the known risk of suicide with use of SSRI antidepressants were
implemented following UK and European reviews of the evidence. The text agreed for the patient
information leaflet (PIL) was developed with patients’ input and was subject to user testing.
The risk of suicide is highlighted in bold and bullet pointed in the first section of the SSRI medicines’ PIL
entitled “Eight important things you need to know about ….. (the SSRI medicine).” Specifically, this
headline section of the PIL states:
• “Some people who are depressed or anxious think of harming or killing themselves. If you
start to feel worse, or think of harming or killing yourself, see your doctor or go to a hospital straight
away”.
Section 2 of the PIL provides more details on thoughts of suicide and worsening depression or anxiety in
bold and key messages are bullet pointed:
“Thoughts of suicide and worsening of your depression or anxiety disorder: If you are depressed
and/or have anxiety disorders you can sometimes have thoughts of harming or killing yourself. These may
be increased when first starting antidepressants, since these medicines all take time to work, usually about
two weeks but sometimes longer. You may be more likely to think like this:
• If you have previously had thoughts about killing or harming yourself.
• If you are a young adult.
Colin Phillips
Acting Senior Coroner
Swansea and Neath Port Talbot
Coroner’s Office
Civic Centre
Oystermouth Road
Swansea
SA1 3SN
By Email: coroner@swansea.gov.uk
Your Ref: CP/AK/1770897
20 January 2021
Information from clinical trials has shown an increased risk of suicidal behaviour in adults aged less
than 25 years with psychiatric conditions who were treated with an antidepressant. If you have
thoughts of harming or killing yourself at any time, contact your doctor or go to a hospital
straight away.
You may find it helpful to tell a relative or close friend that you are depressed or have an anxiety
disorder, and ask them to read this leaflet. You might ask them to tell you if they think your depression
or anxiety is getting worse, or if they are worried about changes in your behaviour.”
We have taken note of your suggestion that the “black box” warnings in the US product information of
suicide warnings for patients ‘would have a more immediate impact’, however we are unable to find
evidence that this is more effective in communicating risk than the current practice in the UK of headlines
and emboldened text supported by extensive user testing to shape the presentation of key safety
messages. Should new data come to light we will review this and see what changes could be made to
support risk communication in the future.
To supplement the patient information, the MHRA has informed healthcare professionals in the UK about
the risk of suicidal behaviour associated with SSRIs via articles in the MHRA’s bulletin Drug Safety Update
in April 2008 and December 2014 available at https://www.gov.uk/drug-safety-update/antidepressantssuicidal-thoughts-and-behaviour.
We also published guidance for prescribers on the MHRA webpage in December 2014 to summarise key
safety messages (https://www.gov.uk/government/publications/ssris-and-snris-use-and-safety/selectiveserotonin-reuptake-inhibitors-ssris-and-serotonin-and-noradrenaline-reuptake-inhibitors-snris-use-andsafety).
The GP handbook, the British National Formulary (BNF) states, “the use of antidepressants has been
linked with suicidal thoughts and behaviour; children, young adults, and patients with a history of suicidal
behaviour are particularly at risk. Where necessary patients should be monitored for suicidal behaviour,
self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed.” The information
in the product information and the BNF should form the basis of a discussion between the doctor and
patient when deciding on the most appropriate medicine for them.
In addition, clinical guidance issued by the National Institute for Health and Care Excellence (NICE)
(Clinical Guideline 90, CG90) on depression in adults recommends that if a person with depression is
started on antidepressants and is considered to be an increased suicide risk or is younger than 30 years
(because of the potential increased prevalence of suicidal thoughts in the early stages of antidepressant
treatment for this group) they should normally be seen after 1 week and frequently thereafter as
appropriate until the risk is no longer considered clinically important. I am unable to comment on the issue
of the prescription for Mr Morgan to be in contravention of NICE guidance you refer to in the report. Should
you wish to follow this up please do contact NICE directly or raise with the General Medical Council.
We are grateful you for notifying us of this tragic case. We have used this information to generate a Yellow
Card report with the reference number ADR 24541651-001. Yellow Card reports help us to continuously
monitor the safety of medicines. if you or the family wish to submit further information, please use this
reference number to ensure it is added to the appropriate case.
Yours sincerely
Dr June Raine
Interim Chief Executive
Medicines and Healthcare products Regulatory Agency
Dr Pedro says
How They Are Related
Richard Smith = director of the UnitedHealth Chronic Disease Initiative at Emory University
Sir Andrew Witty (ex GSK) CEO UnitedHealth Group https://youtu.be/ckcDTFcpifU
UnitedHealth Group in the spotlight at the moment.
https://www.insurancebusinessmag.com/us/news/legal-insights/unitedhealth-affiliates-hit-with-165-million-fine-for-deception-519822.aspx
https://www.fiercehealthcare.com/payers/unitedhealth-shareholders-urge-company-review-utilization-management-practices
annie says
In that spirit, here is Leonie’s comment:
https://www.madinamerica.com/2015/11/study-329-bmj-transparency/
“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.” I agree with both BMJ editors (past and present) on the latter, yet I still have some concerns. Surely if the BMJ had actually learned from this, it would have been more proactive with Study 329, where scientific fraud has so obviously once again prevailed. Is the BMJ, as David Healy suggests, terrified when publishing anything that might make a pharmaceutical company uncomfortable? It’s interesting that an earlier article regarding Study 329 was reviewed and turned down by the BMJ (reviewers included the former editor in chief, Richard Smith).
The findings of Study 329, that Paroxetine was ‘safe and effective for adolescents’ led to the widespread medicating of children with Selective Serotonin ReUptake Inhibitors, subsequently causing many deaths. Saying that universities, authorities and the world of science have a chance to learn from the Chandra case is all well and good, but what have the BMJ actually done to right this latest, very evident wrong? Brown University, GSK and Keller et al are digging their heels in. The BMJ needs to act now while there is still time to put its own house in order. ‘Good men doing nothing’ is just not good enough. The BMJ’s current reputation as one of the leading medical journals is at stake here.”
chris says
Some what sad to see the comment from the great activist Julie Green. I think she passed away 2019 as a direct result of psych drugs but not before she had made thousands of direct and sharp comments on MIA.
“Soooo incredible! The truth wins out. My only hope is that it all overturns in my lifetime…but is that too selfish a thought? Or is it even worth thinking about? Each of us, in his/her own way, carries on. And that’s cool.
Thanks, David.”
Anon says
If we keep relying on re-publishing the same case to underline the the consequences of the failings of thebmj and others it would be useful to highlight others as well. The scandal of the failure to address and publish the consequences of the Study are well known but it happened a decade ago If other examples could be published and re-published it would show the effects are not remedied or as it can seem, in the past.
Dr. David Healy says
Every single publication by NEJM or RSV vaccines fits the same bill. The playbook Lilly introduced in 1991 is the one that underpins Study 329 and all the vaccines studies. This is so obvious it’s hard to see why you ask the question Do you expect the leopard to change its spots or medical journals to grow a backbone ?
D
Anon says
No I can’t see into the future but probably journals will become less relevant There will be other ways of publishing and learning with AI when journals will seem like dead leopards to a new generation .Which gets it’s information already from other sources than journals or text books.
Dr. David Healy says
I can see into the future – until prescription only changes doctors are the consumers not you or anyone else reading these posts and comments and while they are the consumers they will go by the nice guidelines and drug labels and articles in bmj and nejm. You might consult ChatGPT but your doctor won’t and will mention if you consult sources like that you will be ill forever. He will gaslight you and will be struck off by GMC is he doesn’t because they will need to defend the public good against misinformation.
D
Anon says
If we keep re-publishing the same case to underline the the consequences of the failings of thebmj and others it would be useful to highlight others as well. The scandal of the failure to address and publish the consequences of the Study are well known but it happened a decade ago If other examples could be published and re-published rather than relying on well known examples it would show the effects are not remedied or , as it can seem, in the past.
chris says
It will not be long before another Tom Kingston type tragedy of an ordinary member of the public.
I don’t much care how we get there from the past we have got to get there.
Just read that Tony Slattery passed away today.
Informative video here. He didn’t realise he more than likely had akathisia and did all the wrong things with drugs/alcohol, no doubt made himself much worse:
https://m.youtube.com/watch?v=vPfWvws9sI4
Harriet Vogt says
In your chapter – Pharmacological Abuse – in Psychiatric Drugs Explained, you wrote:
‘And once a medical system and a legal process is put in place, some component of what happens next will, on a simply bureaucratic basis, involve actions by the system to perpetuate itself. This is an almost inevitable consequence of any intervention in human affairs. It leaves people grappling with the ‘system’.
This, I’ve discovered in recent years, is THE INSIGHT. The corollary is that, despite the best intentions of many of those working within the healthcare system, the wisdom and experiences of patients, the consumers of care, barely feature, straight into the ‘anecdotal’ poubelle. Unlike FMCG markets, which cannot exist without consumer satisfaction – as you’ve often observed, patients are not the primary consumers of medications and medical devices, doctors are.
Obviously the experiential distance between doctor and patient realities is minimised in surgical procedures – and maximized in psychotropic prescribing – hands on plumbing and carpentry vs what has become, with all the moa baloney, the voodoo end of the business.
There are endless ideologically driven debates about emotional blunting – is it the moa or a ‘side effect’. And all kinds of garbage spouted about neuro-regenerative effects etc. But I’ve never heard anyone but you talk clearly about the actual intended psychopharmacological effects of SSRIs – ‘serenics’, reducing reactivity. If, Tom Kingston’s doctor had conceptualised SSRIs in this way, she would or should have known not to give him the same again. Dexter Johnson’s prescriber wouldn’t or shouldn’t have quadrupled the dose.
But. look at the marketing guidance Dr Morgan was following, theoretically:
1.9.5
If a person’s depression has had no or a limited response to treatment with antidepressant medication alone, and no obvious cause can be found and resolved, discuss further treatment options with the person and make a shared decision on how to proceed based on their clinical need and preferences. Options include:
• adding a group exercise intervention
• switching to a psychological therapy (see the section on suggested treatment options for more severe depression)
• CONTINUING ANTIDEPRESSANT THERAPY BY EITHER INCREASING THE DOSE OR CHANGING THE DRUG. FOR EXAMPLE, BY:
o INCREASING THE DOSE OF THE CURRENT MEDICATION (WITHIN THE LICENSED DOSE RANGE) IF THE MEDICATION IS WELL TOLERATED; BE AWARE THAT HIGHER DOSES OF ANTIDEPRESSANTS MAY NOT BE MORE EFFECTIVE AND CAN INCREASE THE FREQUENCY AND SEVERITY OF SIDE EFFECTS; ENSURE FOLLOW-UP AND FREQUENT MONITORING OF SYMPTOMS AND SIDE EFFECTS AFTER DOSE INCREASES.
o SWITCHING TO ANOTHER MEDICATION IN THE SAME CLASS (FOR EXAMPLE, ANOTHER SSRI)
o switching to a medication of a different class (for example, an SSRI, SNRI, or in secondary care a TCA or MAOI).’
https://www.nice.org.uk/guidance/ng222/chapter/recommendations#choice-of-treatments
Nowhere does it say simply, SSRIs are supposed to have a serenic effect – if your patient is feeling anything but serene – uncharacteristically agitated, anxious, out of control, distressed, angry,suicidal or even homicidal – stop the drug, under no circumstances double the dose or switch to another drug in the same class. It’s commonsense but once you subtract patient experiences from the system, there is no commonsense.
It’s the same with the PIL the MHRA sent to Tania and Ian Morgan after the tragic and avoidable death of their son, Samuel, to assure them that the documentation contained warnings about suidicality. They sent para 2 below as evidence of an appropriate warning.
‘EIGHT IMPORTANT THINGS YOU NEED TO KNOW ABOUT FLUOXETINE 20mg CAPSULES
Para 1Fluoxetine won’t work straight away. Some people taking antidepressants feel worse before feeling better. Your doctor should ask to see you again a couple of weeks after you first start treatment. Tell your doctor if you haven’t started feeling better. See section 3, How to take
Fluoxetine 20mg Capsules.
Para 2 Some people who are depressed or anxious think of harming or killing themselves. If you start to feel worse, or think of harming or killing yourself, see your doctor or go to a hospital straight away. See section 2.
https://www.medicines.org.uk/emc/files/pil.14304.pdf
But, the crunch is the preliminary para – ‘some people taking ADs feel worse before feeling better- you’ll be seen in a couple of weeks’. So, any patient following the logic of this information – could take their own lives imagining their agitated, suicidal state was just the feeling worse before feeling better.
Also, obviously, the ambiguity – of the implication in para 2 that suicdailty is an extension of a previous state of mind – rather than a toxic drug reaction – is at best misleading, at worst , downright dishonest.
You ask – Who will make medicine great again? With a few notable exceptions – imo the answer is not doctors. Good altruistic professionals who seem to have left their critical faculties at the door like a pair of dirty shoes. I think the answer is primarily – patients.
Just as you have changed the system by out playing it at its own game – e.g. revealing buried company research evidence of harm in court – patients have a way in via pharmacovigilance. Weirdly, the system ignores safety signals on social media – but is obliged to pay attention to yellow cards and medical codes. Well done Mark Horowitz and Team PSSD for latching onto that.
I have a dream – literally – that one day every single harmed patient will submit multiple Yellow Cards to the MHRA (or international parallel orgs) and Rxisk Proformas to their GPs – detailing every single adverse reaction they have had to particular drugs – and precisely how these ADEs have been diagnosed or more likely misdiagnosed by healthcare professionals. A Tsunami of patient experience flooding into the system which it will be unable to ignore.