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
chris says
Didn’t take long did it. Thankfully she is not dead.
https://www.msn.com/en-gb/health/other/woman-suicidal-after-taking-same-antidepressants-as-thomas-kingston-issues-warning-over-side-effects/ar-BB1rhyYi
“Lingling Wang, 48, told The Independent she felt she was not made adequately aware of the potential effects of taking antidepressants before she was prescribed them for insomnia and mild anxiety last January.
A year later, the 48-year-old, who previously worked as a senior consultant for a bank, said:
“My life is finished – I lost my job, almost all my friends, I’m bedridden, I have to rely on my family to feed me.”
I hope Lingling Wang finds this site: she does not seem to know she had akathisia and that she is in danger of it returning.
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.
chris says
“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.”
I watched in a psych hospital every single patient who got worse, and they all did, including myself be given – and of course it’s forced if there is resistance – huge doses of neuroleptics. One chap had a stroke after being given 100mg quetiapine. One young woman had screamed out that she wanted to murder someone and then kill herself, it was akathisia, she was pummeled with drugs. They would laugh at your words and dismiss them with ‘well what am I suppose to do’ which is what a consultant said to me through a sarcastic laugh. I replied you could at least do a CYP450 test, he turned to others present and said ‘he knows something’ and just ignored me. After my experience of psych hospitals I have no respect what so ever for psychiatrists or psych nurses. They have done a hell of a lot of damage. The ones who saw the reality early – and I mean the first week it’s difficult not to – got out and did something else – good on them.
annie says
As a double-the-dose type person, when a psychiatrist said he was surprised ‘to hear what had happened to me’ and made no effort to talk to the GP, with the cold-turkey, loads of different pills, and with a very bad attitude. He looked at me quizzically, as if he was not quite understanding something, but he let it go.
The scourge of bad and sloppy practices; The Times has another go
‘David Healy, a professor of psychiatry, told the Kingston inquest that regulators “shied away” from setting out the suicide risk of taking the pills.’
Type of drug taken by Thomas Kingston flagged 40 times by coroners
Lady Gabriella Windsor’s husband was taking two SSRIs, the most commonly prescribed class of antidepressants
https://archive.ph/HZs27
Widely used antidepressants which contributed to the death of Thomas Kingston, the son-in-law of Prince and Princess Michael of Kent, have featured in 40 coroners’ reports aimed at averting future deaths.
Kingston, 45, took his own life in February last year after being prescribed the drugs sertraline and citalopram for anxiety, his inquest last month was told.
Both medicines are in a class known as SSRIs (selective serotonin reuptake inhibitor) which are prescribed to more than four million people as the NHS’s first-choice medicine for anxiety and depression.
Last week Katy Skerrett, the senior coroner for Gloucestershire, said in a prevention of future deaths (PFD) report she was concerned to know “whether there is adequate communication of the risks of suicide” associated with SSRIs, and if guidance on persisting with the drugs or switching to another type was appropriate when a patient had adverse side-effects.
Skerrett is the latest coroner to highlight concerns about SSRIs. Working with the Preventable Deaths Tracker research platform at King’s College London, The Times has found 40 PFD reports which reference the use of either citalopram or sertraline by the deceased person.
The reports identify a range of concerns including the failure to alert patients to the potential side-effects, breaches of prescribing guidelines, not reviewing patients and not keeping records of patients’ behavioural changes while on the medication.
In December 2020 a coroner in South Wales suggested citalopram should come with US-style “black box” warning after the suicide of Samuel Morgan, 25, from Swansea.
• Failure to act on coroners’ findings blamed for thousands of deaths
Morgan began taking citalopram seven days before his death in January 2020. The coroner, Colin Phillips, reported: “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.”
Phillips said that while the drug came with a patient information leaflet, a black box warning “would have a more immediate impact”. He continued: “The simple and clear message in this specific case would be that there is an increased risk of suicidal thinking in young adults.”
The Medicines and Healthcare Products Regulatory Agency (MHRA) rejected the coroner’s suggestion saying the warnings in patient information leaflets had been reviewed and tested.
In May 2023 Michael Spencer, assistant coroner for East Sussex, issued a report about the suicide of Joshua Asprey, 19, who began taking sertraline 18 days before his death. His GP had increased the dosage three days before Asprey took his own life in June 2021.
The coroner expressed concern that the medicines guidebook, the British National Formulary, “does not identify suicidal ideation as a risk of prescribing sertraline”. He said that in two telephone consultations, Asprey’s GP “did not discuss any risk of suicidal ideation associated with commencing or increasing the dose of sertraline”.
In 2016 a coroner in Cambridgeshire expressed concerns about the way a GP, on the advice of a nurse, had prescribed citalopram to Edward Mallen, 18, two weeks before he took his life.
In 2015 Emma Bray, 25, killed herself 17 days after her dosage of sertraline had been increased.
Laura Johnson, an assistant coroner for east London, noted in a PFD report in 2016: “Risks associated with the drug sertraline do not appear to have been communicated to Emma and her family.”
David Healy, a professor of psychiatry, told the Kingston inquest that regulators “shied away” from setting out the suicide risk of taking the pills.
The MHRA said it kept SSRIs under constant review and added: “Following concerns raised by patients and families about how the risk of suicidal behaviours is communicated in the patient leaflets, we have established a new independent expert group to advise the Commission on Human Medicines, which provides expert advice to government ministers.”
tim says
I was a prescriber for forty years and I believe that I was diligent in a commitment to prescribe as safely as possible.
In order to achieve this, I am dependent on unbiased, truthful and reliable information on ADRs.
The prescriber information on SSRIs/SNRIs/ADs appears to have been constructed to deliberately create and reinforce the belief that antidepressant induced suicidal ideation and completed suicide is the result of underlying depression.
Is the Antidepressant Risk Minimisation Expert Working Party going to inform prescribers and patients that those with NO depression, with NO mental illness also die from adverse reactions to antidepressants?
In order to prescribe safely, I need to have a comprehensive understanding of AD induced AKATHISIA, DISINHIBITION and EMOTIONAL BLUNTING.
I need to know that increasing dose or changing AD increases life threatening risk.
I need to be able to accurately diagnose AKATHISIA and not to allow myself or a psychiatrist to misdiagnose this as SMI (Serious Mental Illness) leading to incarceration, forced drugging, with cruel and vicious abuse in an alleged ‘hospital’, which would be more appropriately considered to be a Gulag in my family’s experience.
I need to warn patients of these (and other ADRs such as PSSD) in order to achieve Fair, Full, and Informed Consent.
How many of us are subject to ADR misdiagnosis and loss of liberty, loss of all life’s chances or loss of life because prescriber information on antidepressant ADRs is “Economical With The Truth”?
If the epidemiology of psychiatric ADR misdiagnosis were to be monitored and cost analysed comprehensively, it would seem possible to save vast human suffering, as well as extensive, wasted NHS expenditure of funds which could be released to staff proper hospitals adequately and minimise the ‘Corridor Care’ which is unacceptable to patients, relatives and to dedicated caring staff.
This is a very powerful, important and deeply moving post. Thank you.
chris says
“In order to prescribe safely, I need to have a comprehensive understanding of AD induced AKATHISIA, DISINHIBITION and EMOTIONAL BLUNTING.
I need to know that increasing dose or changing AD increases life threatening risk.
I need to be able to accurately diagnose AKATHISIA and not to allow myself or a psychiatrist to misdiagnose this as SMI (Serious Mental Illness) leading to incarceration, forced drugging, with cruel and vicious abuse in an alleged ‘hospital’, which would be more appropriately considered to be a Gulag in my family’s experience.”
It is unfortunate that this information has not been published on the main media. It is absolutely correct and vital. It is vital that the public know what akathisia and how is distinguish it from anxiety as well as GP’s and other prescribers.
tim says
Chris, I agree. It would appear that the mainstream media in the UK cannot let a day pass without coverage of and/or repeated references to ‘Mental Health’.
They could make an invaluable contribution to Public Health by informing their viewers and listeners about the dangerous ADRs of antidepressants identified above.
It appears that this is now a forbidden subject.
The term: ‘Antidepressant Risk Minimisation Expert Working Party’ is interesting.
How can Antidepressant Risk be Minimised without a public information campaign that informs patients and prescribers in detail re AKATHISIA, DISINHIBITION, EMOTIONAL BLUNTING, and the resulting RISK of VIOLENCE to SELF and/or OTHERS?
Unless these risks are openly and honestly publicised, then the term ‘Risk Minimisation’ is meaningless.
MISSD addressed this public health message with their London Underground advertisements.
The response from Psychiatry’s ‘Defenders of The Faith’ on X/Twitter may explain why the media are unable to address this life-saving opportunity.
Time to revisit the courageous Panorama Series on this vital issue?
annie says
Joanna Moncrieff, an NHS Psychiatrist, has written a new book, out today.
This immensely professional woman, looks very professional, and speaks very professionally.
Other Professors of Psychiatry, seem to think that she is ‘fair game’ to bait and needle because she wears a smart dress and has lovely hair. ” Put simply, the emperor has no clothes –
“People have been profoundly misled about antidepressants.
Not only have they never been shown to rectify a chemical imbalance or any other abnormality, but – as I shall explain – they actually interfere with the normal state of the brain, just like alcohol and other mind-altering drugs. This is how they can produce potentially devastating side-effects – from rare suicidal thoughts to severe sexual problems.”
The Royal College of Psychiatrists research and academic work has hardly been a resounding success. They are way behind the times.
Chemically Imbalanced: The Making And Unmaking Of The Serotonin Myth by Joanna Moncrieff is published on Thursday (Flint, £20).
Medicating misery by doling out antidepressants is based on a myth: NHS psychiatrist PROFESSOR JOANNA MONCRIEFF reveals the shameful truth about Big Pharma
By PROFESSOR JOANNA MONCRIEFF
https://www.dailymail.co.uk/health/article-14279653/Medicating-misery-antidepressants-myth-NHS-psychiatrist-PROFESSOR-JOANNA-MONCRIEFF.html
The fact is the theory that depression is caused by low serotonin is not supported by reliable evidence. Put simply, the emperor has no clothes – and this matters, because our widespread use of antidepressants for mental health problems is grounded in this myth.
Robert Howard@ProfRobHoward
I assume he is referring to my UCL colleague here, since she does look (from this picture, anyway) as though she has been completely transformed by the money and prestige associated with her famous new book.
Duncan Double@DBDouble
Too many psychiatrists have been seduced by money and prestige
“ – the disease of depression. How could people resist this sort of message, especially when it was delivered not just by drug firms, but by their own doctors?
Harriet Vogt says
Just watched – at times endured – this 90 minute parliamentary – ‘Debate on a motion on the performance of the Medicines and healthcare products regulatory agency’ – brought by no holds barred Esther McVey. Starts at 16:30pm
https://parliamentlive.tv/Event/Index/ee611dc4-7725-4b7e-b925-9d6da0b6f0d2
A flavour in 90 seconds: ‘MHRA needs substantial revision’, ’Cumberlege’, ’the regulator has a duty to work for and with patients’, ‘YC system failing’, ‘gross under-reporting’, ‘delayed vaccine injury reporting’, ‘safety signals missed’, COIs, pharma funded, £2.2bn cost of ADEs, ‘YC is voluntary should be mandatory for all HCPs (except lots have no clue), ‘no follow up on YC reports’, ‘MPs don’t look until a crisis’, ’keeping things secret’. (Graham Stringer) June Raine’s ‘enabler’ comment (oops, bite off your tongue), ‘pharmaceutical sharks’, ‘GSK knew of paroxetine risk of suicide in children’. ‘Access to the data, vaccine deaths’, ‘mesh no post marketing surveillance’. Cumberlege (repeats), IMMDS, Primodos affected seeking justice ever since’. (APPG Beyond pills members) ADs overprescribed, social prescribing, need for withdrawal services, ‘patients suicide in withdrawal’, ‘RFK’, ‘SSRI’s sexual dysfunction’ (Dr Luke Evans, Tory Shadow Undersec for H & SC – has supported one PSSD patient harmed by mirtazapine (very smart campaigner, mostly bed-bound) ‘The duty of the regulator was to protect women. but they chose to protect the manufacturer instead’ (Neil Duncan-Jordan, Labour, Poole, supporting a Primodos harmed family).
Karin Smuth unimpressive bunny in the headlights reading from a script.
‘Verdict of MPs today – the MHRA is guilty as charged & in need of significant reform. Many MPs rose to speak about the failings of the Medicines & Healthcare products Regulatory Agency & medical scandals from Primados to surgical mesh, sodium valproate to its yellow card scheme.’ Esther McVey
I did think a little self-flagellation might have be in order since politicians have allowed the regulators to behave like this for years – but…
There is unlikely to be a moment when the regulators will be more susceptible to listening. If feeling so inclined, Tim, it might be worth sending this powerful comment- with your dual authority as clinician and someone who cares, personally, to Dr Cave referencing the ongoing AD comms safety review.
Looking at the PIL for fluoxetine again – the akathisia information is woefully inadequate:
‘f you feel restless and feel like you can’t sit or stand still, tell your doctor. Increasing the dose of Fluoxetine capsules may make these feelings worse. See section 4, Possible side-effects
If you feel restless and cannot sit or stand still, you may have akathisia; increasing your dose of Fluoxetine may make you feel worse. If you feel like this, contact your doctor. ‘https://www.medicines.org.uk/emc/files/pil.11909.pdf
Akathisia mischaracterised – and treated with the same level of concern as a bad case of indigestion.
Harriet Vogt says
Always brilliantly on the case, Marion has just posted the Hansard transcript of the debate on X. For anyone with longer than 90 seconds, worth a read.
https://hansard.parliament.uk/Commons/2025-01-16/debates/4BF8018B-9662-427B-A580-2EBB7770D164/MedicinesAndHealthcareProductsRegulatoryAgency#
Correction to my own scribbled key word version – Labour’s Minister of State for Health (Secondary Care) is not Karin Smuth to rhyme with truth, but Karin Smyth to rhyme with I’m not sure what.
Shout me down, but I feel some sympathy for the hard working bureaucrats at the MHRA . They didn’t develop their own company driven, patient disconnected system – though i suppose they ran with it. Let’;s hope this is a watershed moment , Who needs RFKJr?
Anon says
A manifesto for preventing future deaths
It’s too late for reform, the death investigation system must transform
Dr Georgia Richards
Jan 16
Yesterday, The Times ran a series of articles featuring the Preventable Deaths Tracker and the failures in the death investigation system.
Why overhauling the coroner’s system could save lives
Failure to act on coroners’ advice blamed for thousands of deaths
Type of drug taken by Thomas Kingston flagged 40 times by coroners
My mum took her life after hospital. Yet lessons won’t be learnt
The article I personally wrote for The Times shares my manifesto for how the death investigation system must transform to truly “learn lessons”.
.
A huge thank you to Senior Writer Sean O’Neill for supporting my work and sharing his personal experience of the inquest system and News Reporter Lottie Hayton. Below, I share my full transcript with you.
If you lose a loved one following a failure in care, you might assume that a robust system is ready to investigate and act. Instead, those who should be grieving realise they must become campaigners for action to be taken. This creates disparities in an already siloed, neglected, and poorly understood “system” where reputation trumps truth.
Thousands of families experience this “system” every year. Nearly 37,000 inquests were opened in 2023 to investigate who, how, when and where the deaths occurred. Inquests vary widely – some last weeks and have juries while others are concluded in writing without a court hearing.
Regardless of the type, inquests involve immense resources and are hugely distressing for all involved – those who relive the trauma of their loss or provide evidence as witnesses. So what happens after the investigation to learn from these failures?
Coroners have a statutory duty to write to organisations, including hospitals or the government, if they believe that action should be taken to prevent future deaths. These reports, called Prevention of Future Deaths reports or PFDs, have sat statically on the Judiciary website for nearly 12 years. No one could systematically use this information – nor did anyone know how many reports were being written, who received reports, if responses were sent, and if action was taken following the report.
In 2023, only 1.5 per cent of inquests resulted in a PFD report – that’s just 547 reports. And often, when reports are written, they omit basic information and are lost in translation.
Emails won’t prevent future deaths
The flow of such critical information, which has the potential to save lives, relies on the email etiquette of thousands of recipients. First, the coroner must email the report to the addressee – and there are likely multiple addressees. Next, the addressees must receive the report, formulate a response, and reply within 56 days – outlining any action taken. If the coroner’s office receives a reply, they forward it, along with the report, to the Chief Coroner’s Office, who is responsible for redacting and publishing reports.
If my calculations are correct, that’s a minimum of three email exchanges for a single report with one addressee. Since 5,443 reports have been published as of 15 December 2024, that’s at least 16,329 unnecessary emails. It gets worse. Reports are then manually published on the Judiciary website, causing a wealth of errors and inconsistencies that made it almost impossible to make any sense of this information.
So, is there a better way to prevent future deaths?
Other jurisdictions do not rely on thousands of emails to learn from deaths. In Australia and New Zealand, information from every inquest, not just a biased selection of 1.5% of deaths, is collated in the National Coronial Information System (NCIS). The NCIS has been functioning for over 25 years and is actively used to save lives.
Learning from the antipodeans
Learning from the antipodeans
Dr Georgia Richards
·
March 21, 2024
Read full story
The NCIS has changed policies that have reduced deaths of young children due to strangulation by blind/curtain cords, unintentional cigarette-related fires, quad bike fatalities, and improved child pedestrian safety, among others.
The NCIS began in response to recommendations made following the Royal Commission into Aboriginal Deaths in Custody. Its governance, licensing and funding had to be agreed and approved by the varying political leaders of each state and territory, a challenge that the English and Welsh system does not need to overcome. The core funders are the Justice departments in every Australian state and territory, the New Zealand Ministry of Justice, and several government agencies. It’s a cross-cutting resource that benefits and is valued by all.
The NCIS employs ten staff and is hosted by the Victorian Department of Justice and Community Safety. I can only imagine what the Preventable Deaths Tracker could achieve with ten staff! It is, however, not just about the data. In Victoria, the coroner’s court is also supported by the Coronial Prevention Unit (CPU) and the Victorian Insitute of Forensic Medicine (VIFM).
The CPU strengthens the preventative role of coroners, while VIFM provides independent scientific services, including timely autopsies, toxicology, organ donation, and support for victims and the bereaved. VIFM’s direct link with Monash University means that its education of the next generation helps reduce workforce shortages and provides the necessary training to upskill professionals. They conduct rigorous academic research that results in the evidence required to continually improve the justice system, public health and death prevention.
Transforming the system
The death investigation system in England and Wales is in such a mess that another call for reform is not enough. The same deaths continue to occur. The inaction and inability to “learn lessons” following preventable deaths is harming us – the living.
A system without a memory that relies on the goodwill of dedicated individuals and campaigns by bereaved families for any action to be taken should be a national scandal. To truly “learn lessons” from preventable deaths, we cannot continue current inefficient and outdated practices.
The transfer and collation of life-saving information via email must stop. The Preventable Deaths Tracker (PDT) provides a blueprint for how essential statistics can be tracked and monitored in real time.
More oversight and annual reports don’t help organisations thrive. Instead, the PDT measures progress and can identify safety signals for action. With sustainable funding and government support, the PDT could expand to include all inquests – creating the English and Welsh Coronial Information System, which is used by a dedicated, independent, interdisciplinary research unit working alongside the Coroner Service to inform death prevention policy and practice. Until then, the Preventable Deaths Tracker will keep tracking.
My article for The Times was published online here and on page 17 of Wednesday’s print newspaper.
chris says
https://www.dailymail.co.uk/news/article-14294423/Lady-Gabriella-Windsors-husband-Thomas-death-sparks-review-antidepressants-linked-suicide.html
“But the MHRA has now opened a review into sertraline and citalopram and said it originally set up an expert working group in 2022.
It therefore denied this review was prompted by Mr Kingston’s case, instead claiming it had taken time to assemble the 20-member panel.
The regulator did confirm that it had received Ms Skerrett’s PDF report and was ‘carefully considering’ its response.
Dr Alison Cave, chief safety officer at the MHRA, told The Times: ‘Following concerns raised by patients and families about how the risk of suicidal behaviours is communicated in the patient leaflets, we have established a new independent expert group to advise the Commission on Human Medicines, which provides expert advice to government ministers.’
It was also revealed that thousands of deaths could be prevented every year if public bodies took action over concerns highlighted at inquests.”
Inferd thousands of deaths have happened – will there be prosecutions?
Who are the 20 member panel and why has it taken 2 plus years?
“It was also revealed that thousands of deaths could be prevented every year if public bodies took action over concerns highlighted at inquests.”
In the case of akathisia inquests are far too slow we have the information and evidence things need to happen fast.
“40 PFD reports which reference the use of either citalopram or sertraline by the deceased person.”
There has been far far more harmed or died than that.
“Mr Phillips reported: ‘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.”
The precise effect of the medication is known has a name, it is: akathisia, which we have been discussing and defining on here and else where for many years.
annie says
This is the final report of the work of the Committee on Safety of Medicines’ (CSM) Expert Working Group (EWG) on SSRIs, which was established in May 2003 to investigate ongoing safety concerns with these medicines.
Evidence from experts A number of experts were invited to give evidence to the EWG on specific aspects of the review, including Dr Andrew Herxheimer, Professor David Healy, Mr Charles Medawar and Professor Munir Pirmohamed.
Dr (now Professor) David Healy raised the issue of suicidal behaviour with SSRIs in his publication ‘A Failure to Warn’ in 19999 . Concerns were also raised that SSRIs may be associated with the development of psychomotor restlessness/akathisia-like restlessness, which in turn may precipitate agitation and suicidal behaviour10.
Healy D (1999): ‘A Failure to Warn [editorial].’ Int J Risk Safety Med 12: 151-6
The CSM considered the available data in June 2000 and concluded that it was impossible to answer the question of whether SSRIs caused suicidal behaviour in a small subpopulation of patients. It was decided that the issue should be kept under review and formally reviewed every two to three years.
https://study329.org/wp-content/uploads/2015/01/CSMReportonSSRISafety1.pdf
More than 100 alerts over deaths linked to antidepressants taken by Thomas Kingston
The UK’s medicines regulator is reviewing safety alerts for 30 common antidepressants
https://www.independent.co.uk/news/health/antidepressant-citalopram-thomas-kingston-b2658665.html
The UK’s medicines regulator, the Medicines and Healthcare Products Regulatory Agency (MHRA) said it is undertaking a review of safety warnings for 30 antidepressants including citalopram and prozac.
The MHRA review of the medication, commissioned by former minister Maria Caulfield, is looking at the effectiveness of safety warnings following families’ concerns over the loss of their loved ones.
But the regulator said it could not provide an update on the review as it is ongoing.
It added: “It’s important to note that the patient information leaflet provided in packs of citalopram as well as the summary of product characteristics for healthcare professionals includes information about the possibility of feeling increased anxiety at the start of treatment as well as the risk of having thoughts about suicide with the advice that patients should contact their doctor or go to hospital straight away.”
Prozac one of 30 antidepressants probed by UK watchdog over links to suicide
Exclusive: The Medicines and Healthcare products Regulatory Agency is to look at the effectiveness of side-effect warnings in relation to the most commonly prescribed antidepressants on the UK market
https://archive.is/kG9uS
The MHRA said it could not confirm the scope of the review or what actions could be taken as a result, as it was still convening its panel of experts.
It told The Independent: “We are currently finalising the core membership of the expert working group considering risk minimisation measures for antidepressants, and anticipate that their first meeting will take place in July. The group will be considering all antidepressants on the UK market.”
Professor Davies highlighted concerns over the regulator’s ability to conduct the review. He said: “The MHRA is far too close with the industry to be objective for this review, in my view. It is 100 per cent funded by the pharmaceutical industry. There are serious concerns about what we call regulatory capture, which is when it is far too close to the industry it is purporting to independently regulate.”
An MHRA spokesperson said the agency has “robust conflict-of-interest mechanisms covering MHRA staff, board members and those who give independent, expert advice on MHRA committees”, adding: “These mitigate any potential conflicts of interest effectively.”
Like Dr. Ian Hudson, MHRA, formerly GSK, was allegedly not allowed to attend meetings about Seroxat. Tricky dicky at the MHRA
chris says
In all the media presentation of Axel Rudakubana today or previously, no where does it say if he was medicated for his autism and anxiety. Does anyone know the answer to this ?
mary H. says
I bet many of us are wondering the same thing! It’s obvious to all that something major has happened to him when you look at the video of him at 13 years of age and his demeanour now. Again, we’ll hear about everything EXCEPT the possible role of ‘medication’ – and on we’ll go to the next case in Birmingham with our thoughts going in exactly the same direction. When will our nation wake up?
chris says
People who are new to all this may find our position difficult. Please watch this video:
https://m.youtube.com/watch?v=CLgt3zhJ0hk
chris says
https://www.dailymail.co.uk/news/article-14324637/PETER-HITCHENS-sneaking-suspicion-Southport-child-killer-Axel-Rudakubana-suddenly-turned-violence-age-13.html
So this is behind a pay wall but from the comments it is inferred Axel Rudakubana was subjecting himself to Marijuana and Peter Hitchens suspects may have been the cause of his behaviour. Does anyone know what Hitchens actually said – if it known that Rudakubana did use Marijuana ?
tim says
Chris – I don’t have. an answer, but I have asked the same question to myself, as no doubt have many who comment here.
“The police are not looking for anyone else”. “Loner”. “Didn’t show any emotion”.
Yesterday, the Prime Minister referred to increasing violence in teenagers and young people.
Doesn’t this coincide with increase in SSRIs/ADs and psychotropic drugs prescribed for young people?
Instead of head-scratching for a motive in such cases, why can’t those investigating start by identifying all prescription Rx preceding these heartbreaking violent incidents?
That might genuinely allow the phrase: ‘Lessons will be learned’ to have both meaning and outcome.
d says
The Coroner’s inquests opened in August and I expect will finish this later this year.
https://www.bbc.com/news/articles/cx2gk9kyngno
If appropriate there will be the opportunity for three Regulation 28 reports as to what action should be taken to prevent future deaths.
chris says
“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. ”
So this is from the MHRA in reply to the coroner re Samuel Morgan.
“These may be increased when first starting antidepressants, since these medicines all take time to work, usually about two weeks but sometimes longer. ”
This is what does the damage. Akathisia induced suicide ideation is horrific and it is absolutely unacceptable wording right here: “thoughts of harming or killing yourself”
It shows a total lack of understanding of how serious akathisia is. It’s not just thoughts it’s been intensely tortured by horrific pain at the same time as having intense suicide ideation inflicted upon you.
Two weeks when your head is on fire and exploding is not acceptable it has to stop.
Dr. David Healy says
Absolutely this is the key point and MHRA are missing the boat badly
D
Mike says
Can anyone give me some advice on lifestyle changes that may reduce symptoms of PSSD? I’m not getting any younger and age is a factor. There is no treatment at the moment so my biggest concerns are ED,Anhedonia and Premature ejaculation. I see people in their prime on reddit talking about how much this condition affects them which I completely understand but I’m 41 and as a man time is not going to do me any favours in terms of recovery especially as my testosterone levels arediminishing every year.
susanne 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)
Cite this as: BMJ 2025;388:r67
Rapid Response:
Need for systematic recording medication history for all suicides determined at a coroner’s office
Dear Editor:
Research on drug-related suicide is challenging. Post-marketing surveillance suffers from underreporting, for multiple reasons: after completed suicide, the patient cannot report; the family may be unaware that the patient had used a suspicious medication; and the family and the physician may be unaware of a potential link between this exposure and suicide. Awareness of underreporting demands a pharmacovigilance approach different from passive collection of single reports, where causality cannot be established.
Furthermore, it is nearly impossible to detect an increase in suicide rate with regular research designs, such as cohort studies. Power analysis shows that to establish a doubling in baseline yearly suicide incidence rate (from 0.00014 to 0.00028, at α=0.05, power 80%), the population exposed should be over 7 million, and to detect a 10% increase (from 0.00014 to 0.00015) needs a population of over one billion (!) – calculations done using online calculator: https://clincalc.com/stats/samplesize.aspx
A promising approach would be systematic recording medication history for all suicides determined at a coroner’s or a medical examiner’s office, preferably using a cross-check of healthcare records. Comparing the rate of suicide in people exposed to a specific drug to the rate of suicide in a control population might allow estimates for drug-induced suicides. After I got negative answers to my query by FOIA from medical examiner’s offices of several states in the U.S.A., it became clear to me that such information is not routinely obtained at the current time. I would recommend introducing a routine retrieving of drug history in all suicides, using cross-check of healthcare records
Mayer Brezis
Professor of Medicine, MD MPH
Hadassah-Hebrew University Medical Center Jerusalem, Israel
Braun School of Public Health, Ein Kerem Campus, Jerusalem, Israel
Dr. David Healy says
This is an obvious step but is not going to happen soon. Having a system like this would conceded that the good drugs can have problems – which would be as disastrous as conceding the bad drugs can do good things – the bad drugs being former prescription drugs
D
Dr. David Healy says
Let me add to this and ask that there are no comments about complaints that are not drug related. Coroners in the UK and other systems in others countries get a box to tick in the case of a street drug induced suicide or homicide – because they are illegal and no benefit can be legally set against their risks.
In the case of a prescription drug, these have been licensed because a benefit may be possible. In which case death occurs during the treatment of a condition and the coroner says this. Which for most doctors defaults into the illness killed someone.
Meyer Brevis has been working on finasteride rather than suicides in general and for him it seems obvious that becoming suicidal has nothing to do with the condition being treated. This is a line that companies and regulators have found possible to stand against for nearly two decades. It may change soon but the real change needed is a change that asks coroners to consider whether in the treatment of this condition a particular drug given could have caused a suicide – or other death.
The resistance of health services to other complaints that have nothing to do with meds may have overlapping features in some instances but risks derailing the conversation about prescription drug induced problems
D
chris says
“It may change soon but the real change needed is a change that asks coroners to consider whether in the treatment of this condition a particular drug given could have caused a suicide – or other death.”
How is this to be brought about, is a law change required or is it about awareness and education of coroner’s on serious adverse drug reactions causing suicide or both and or what else?
I’m guessing you have already tried on the education?
Dr. David Healy says
Good question. In the religious belief system that is prescription drugs, nothing changes fast – it has taken the Catholic Church a long time to wake up and accept gluten in Eucharist can cause problems. Until then nobody was likely to believe that God or a priest could maybe kill you.
At present the drug is embodied in a treatment ritual that turns everything into the body and blood of Xt with the consecrated doctors administering the sacrament. We need a Lutheran or Berlin Wall moment. This is not a matter of education, Just the opposite – the education all aims at defending the system. It needs an emotional moment. A moment of outrage
I hope to post some bits about this on DH and RxISK in weeks to come but have my hands also full of other things. Will need help to get people arguing – getting emotional – about some of these things.
D
chris says
“I would recommend introducing a routine retrieving of drug history in all suicides,”
This is interesting, again I have experience that is relevant.
In my first complaint I asked why I had been subject to polypharmacy. I stated this had vastly exacerbated my condition.
The reply stunned me.
They stated I had never been subject to polypharmacy and that my medical records stated I had been given one drug after being weaned off the other. It was a blatant lie proven by a letter and documents from the trust two years previous listing drugs to be given at night same time.
So do not expect the truth in medical records.
Dr Pedro says
Coroners just don’t get it.
On the 6 March 2024, Mr. Ford had a telephone consultation with his GP. He explained that he had experienced suicidal thoughts on the 1 March 2024, but stated that he would not act on these thoughts. He described clear protective factors. The GP prescribed anti- depressants and a review appointment was set for the 20 March 2024. Crisis information was also provided by the GP. On the evening of the 9 March 2024, Mr. Ford had a disagreement with his partner. At around 0850 on the 10 March 2024 he left home. At 1035 he is seen on CCTV buying a length of rope. At 1350 he was found hanging in Bedfords Park, Romford. Emergency services were called and paramedics pronounced his life extinct on scene. Police attended and deemed the circumstances as non-suspicious. There were no substances found on toxicology which would have prevented Mr. Ford from forming an intention to take his own life.
Vague reference to “antidepressants” is unhelpful. The name of the specific drug is essential.
If one brand of fizzy drink was found to be contaminated and caused a death it would be named.
And what “substances found on toxicology” would have prevented him taking his own life?
https://www.judiciary.uk/prevention-of-future-death-reports/dean-ford-prevention-of-future-deaths-report/
Dr. David Healy says
This is a fascinating case – the coroner says there was no drug present that might have compromised his intent. She just doesn’t appear to get it.
Prior to going to his doctor, when drug free, DF had gone to mental health team said he was out of sorts but not intending to kill himself. They do not appear to have seen him as mentally ill or at risk and didn’t complete a detailed risk assessment. The coroner blames the lack of risk assessment and lack of mental health services for people who are not mentally ill. She wants the health body involved to get more people spending more time doing paperwork – anything except accept the obvious – putting someone who is not mentally ill on psychotropic meds can kill them
What would the risk assessment have said if written? How about – this man is at no risk of suicide unless he goes along to his family doctor and is put on an antidepressant?
D
annie says
What I find so monumentally stupid about this whole thing, is that so many are left with no conclusion.
Doctors are supposed to be Medical people. What are drugs, but medical.
It seems to me, and we hear this constantly, how ‘the man had a row with his wife’; a myriad of personal problems, and they get themselves drawn in to peoples private lives, for which they have no experience in dealing with. They go off at tangents, latching on to things and making a meal of it. This sort of thing happens constantly. Tell a doctor something and before you know it, this becomes the sole reason for what may become an horrific life-ending tragedy.
If you are still here to tell the tale, they will always put personal problems before medication problems. This is so small-minded, that a person with a medical degree, prefers to loop-the-loop around personal issues. They get themselves fixated and the more they interfere in things that are completely extraneous to their own lives, the more they get confused and lost.
They latched on to me, as if I was person in a movie. He did that, so she did that. It was amazing to me that doctors prodded and poked in to my private life. I did not expect medical people to act like this, and the more they interfered, the further away from medication we got. If someone asks me a question, I answer it, just honestly and I fell in, hook, line and sinker.
The psychiatrist seemed much too overly preoccupied with our lives. He wrote pages and pages of stuff as, at the time, I thought his preoccupation was harmless. He seemed almost endlessly fascinated. All this was sent to my surgery where the GP was also doing her best to put her oar in, muddying the waters further to the depths.
Amongst all this, Seroxat appeared, written in copiously. On/Off, Off it, Restarted it. Very little personal opinion to Seroxat, just the continuous On it/Off it repartee.
The drug was Medical. The medical doctors, were so individually invested in writing their script for the movie, it completely passed them by. So, the blindingly obvious became the wrong script they wrote for the wrong movie.
When I left them, their ending left no doubt that their story was the one to follow.
chris says
https://globalnews.ca/video/10839910/womans-maid-procedure-blocked-by-b-c-judge
Interesting video we can expect a lot more of this and to start happening in the UK with the push for assisted death.
chris says
“In a courageous, dignified and long interview on BBC Radio 4’s Today programme this morning, (07 – 32 GMT) the grieving parents of the late Thomas Kingston provided public health awareness information regarding the risks of SSRIs. It was deeply moving.
They included a recommendation that patients should sign a record of ADR information given to them before an antidepressant prescription is issued.
What would work for me (‘as a treatment label that worked’) would be a coloured,, illustrated patient leaflet given with every dispensed SSRI/SNRI/AD, which contained the information from:
‘Restoring The Magic to Healthcare’ – above.
How many deaths, destroyed lives and heartbroken families could this prevent?”
Tim
Thousands and on going.
They should also have interviewed yourself and David to bring precision and expertise to what needs to happen as a matter of emergency as we see horror show after horror show.
To be clear to everyone new to this: It is psychiatric and other drugs which in some people cause them to be suicidal and violent. The condition which causes this is called akathisia, it is almost never correctly diagnosed and is seen as either anxiety or serious mental illness… psychosis depending on how bad the akathisia is. It happens on starting a drug, after sometime being on the drug, if there is a change in dose, going from one drug to another quickly, after the drug has been stopped days, months, even years after.
annie says
BBC Today R4 interviewed Thomas Kingston’s parents. After the interview, they would be talking to an expert to discuss this further.
07.32 Jill and Martin Kingston
08.14 Professor Allan Young
https://www.bbc.co.uk/sounds/play/m0027ltn
Jill and Martin Kingston, poignant, brave and with devastating words of clarity ‘leaning in to the pain’, and offering their suggestions to improve the current situation.
The expert psychiatrist, ‘I note that Mr. Kingston had an anxiety disorder – there does seem to be an impulsive nature –
I found this a deeply offensive rebuttal, to the Kingston’s, the Coroner’s Report and the Psychiatric Report, as referenced by Mr. Kingston.
Most Media are covering the story
Parents of Lady Gabriella Windsor’s husband Thomas Kingston break down in tears as they speak for first time since he took his own life to call for new warnings about anti-depressant ‘side effects’
https://www.dailymail.co.uk/news/article-14358017/We-lovely-lunch-fell-asleep-woke-Tom-missing-nightmare-started-Family-Lady-Gabriella-Windsors-husband-speak-time-took-life.html
susanne says
Mrs Kingston told the Today programme she was aware of why people take SSRIs.
‘We have many friends who are on them, and we totally understand why they’re on them at the same time,’ she said.
On the day of his death, this statement by Jill Kingston should hopefully be heeded as a warning to their many friends who are taking them And It does reveal how normalised the taking of anti depressants has become in all sections of society.
The parents of Thomas Kingston have it seems had serious discussions with psychiatrists hence the care not to ‘scaremonger’ but also some very serious thought and probably discussion with campaigners has gone into suggestions for change which go further ,and could perhaps gone even further, than just requiring verbal consent.It must be proven by written consent Wonder how far that will get.The issue of pharma involvement hasn’t been flagged up. Maybe they played safe on that to get media cover. They have alerted so many by publicising their experience Hopefully some will be saved by their courage in going public from the horror of drug induced suicide.
annie says
Jill and Martin Kingston, employed Professor David Healy as the Consultant, they did not employ Professor Allan Young.
I would wager that BBC Today R4 researchers asked The Royal College of Psychiatrists for someone to be interviewed about this case and antidepressants. Throughout most discussions on antidepressants on BBC Today R4, it is mostly Professor Sir Simon Wessely. This time it wasn’t.
Did they fancy a change from someone, perhaps with a different point of view?
‘But the consultant we employed for the inquest took the view that there were probably better ways in which he could have been helped without prescribing the medication drugs’
‘Particularly because he was definitely not depressed.’
https://holeousia.com/2025/02/04/jill-and-martin-kingston/
MISSD
@MISSDFoundation
Medication-induced #suicide isn’t rare and #akathisia, the disorder that often precipitates iatrogenic suicide, self harm & violence shouldn’t be kept in the dark. After we presented to @rcpsych ‘s International Congress years ago, they promised to add prevention info and akathisia education/training to help prescribers and patients. However, it seems this has not been done.
@emmabarnett
Our presentation to RCP https://www.youtube.com/watch?v=rEu6c6UHUos&t=9s
Martin Kingston:
Yes, and the level of both, I think, misinformation and no information. The misinformation is something you’ve covered already on the Today program with your interview with Joanna Moncrieff, talking to her about what is described sometimes as the serotonin myth or the chemical imbalance myth.
https://holeousia.com/2025/01/25/serotonin-and-the-chemical-imbalance-theory/
RCP talks the talk but does not walk the walk
chris says
“Martin Kingston:
Yes, and the level of both, I think, misinformation and no information. The misinformation is something you’ve covered already on the Today program with your interview with Joanna Moncrieff, talking to her about what is described sometimes as the serotonin myth or the chemical imbalance myth.”
And now we have JFK Jr and the Dailymail seemingly promoting Methylene Blue the basis for early antipsychotics and antidepressants
Ofcourse they are not saying that nor the harms of promethazine and imipramine:
https://www.dailymail.co.uk/health/article-14368619/rfk-jr-mystery-blue-drink-doctors-reveal.html