How Many Coroners to turn on that lightbulb?

Coroners Reports

Robin Williams’ close friends have expressed the opinion that the drugs he was prescribed caused his suicide. Following his death, the media frenzy has once again brought ‘mental illness’ to the forefront of peoples’ minds. Opinions have varied hugely, ranging from the unfounded – “vastly underdiagnosed ‘chemical’ depression” to the over-simplification “if [suicide victims] could see the impact their death has had on those left behind, they’d know that their life had value and meaning”.

Despite the opinions of Robin Williams’ close friends, his death has been used to promote the unfounded ‘chemical imbalance’ puffery and push pills to correct this said ‘imbalance’ – a travesty in my opinion. One article quoted Dr David Husted of the JFK Medical Centre psychiatry program, who said “..the general public often doesn’t understand about depression: It’s all connected to brain chemistry. Essentially, there’s a ‘glitch’…”. He went on to state that “depression is treatable if people are willing to give treatments — which include therapy and antidepressant medications – a chance”.

So what if Robin Williams’ friends are right and the drugs are killing people? This March two different coroners, one in the UK and one in Ireland, expressed concerns regarding antidepressants and their ability to induce suicide. It seems that more and more coroners are willing to speak out about prescription drug-induced suicide. Recently, Jacqueline Lake (a UK coroner), sent a report to the NHS regarding the death and subsequent inquest of Susan Poore, aged 65, from Norfolk. This report has been released online.

A regulation 28 report can be filed by a UK coroner, if, following an inquest, he/she perceives a risk of future similar deaths. A coroner has a duty to write a report under regulation 28 of the Coroners (Inquests) Regulations 2013, where there is a risk of further deaths occurring in similar circumstances as the deceased.

In Mrs Poore’s inquest report, the coroner raised concerns over the effect that the prescription drugs had on her.  Mrs Poore was prescribed Mirtazapine on 29th March 2012. 4 weeks later this antidepressant was stopped and changed to the SSRI Fluoxetine (prozac). 10 days later Mrs Poore walked in front of a train and was killed instantly. The coroner stated in her report that the ‘mode of death’ was out of character for Mrs Poore and that her depression deteriorated following the prescription of antidepressant drugs.

While researching regulation 28 reports, I came across another report which was sent by a different coroner, also to the NHS. Nine weeks before Mrs Poore died, a young man in a young offenders institute also died by suicide. Jordon Anthony Buckton, aged 20, was also prescribed Fluoxetine/Prozac a month before his death. Dorset coroner, Sheriff Stanhope Payne, raised a number of concerns in his report, including that the deceased was never monitored for the emergence of suicidality.

Despite the warnings of increased suicidality with all SSRIs, including Prozac, the GP who prescribed the drug to Jordan never actually met him or even checked to ensure he was doing okay. Despite never seeing Jordan, she stated that she ‘felt he was depressed’. An expert witness also gave evidence at the inquest that the NICE guidlines recommend monitoring following the prescription of antidepressants.

So, two suicides, same drug, same time scale, same steps taken – absolutely none! So I ask again, how many coroners will it take? Will Robin Williams’s death serve as the catalyst for opening peoples’ eyes to the dangers of prescription drugs; a posthumous starring role in ‘awakenings the sequel’? 

Coroner Jacqueline Lake’s Reg 28 Report.

Coroner Sheriff Stanhope Payne’s Reg 28 Report.

Friend’s opinion on Robin Williams’ death here and here.

A list of all the coroners who have raised concerns regarding prescription drugs will be compiled very soon.

3 thoughts on “How Many Coroners to turn on that lightbulb?

  1. An excellent post again Leonie. Regulation 28 looks like a huge step forward in acknowledging that a questionable event has occurred. I would hope that Regulation 28 of the Coroners (Inquests) Regulations 2013 (UK) would finally challenge the MHRA to confront the undeniable dangers of antidepressants for many people and that doctors would be forced to closely monitor everyone being prescribed SSRIs etc.

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