May 7 2019

On January 25th this year, 17-year-old Billy McVea was found hanged in the back garden of his home in Uttoxeter, Staffordshire.

His inquest last week heard that Billy, who worked as a builder’s labourer, had experienced a recent break-up in a relationship and had been involved in a road traffic collision, which both contributed to his state of mind.

Coroner Margaret Jones told the court that Billy had been diagnosed with “oppositional defiant disorder”. He had a history of behavioural difficulties, also of hyperactivity and had been in contact with mental health services since 2005. She added: “His behaviour had improved with some medication, but that had been changed in 2014 following a different diagnosis.”

For “conduct disorders in children and young people”, NICE recommends anti-psychotics and antidepressants, while others claim that stimulants such as Ritalin and Atomoxetine are effective. All of these drugs carry a heightened risk of suicidal ideation when prescribed to children.


May 3 2019

On January 10th last year, 13-year-old schoolboy Bradley Trevarthen was found hanging at his home in Durrington, Wiltshire.

At his inquest in Salisbury last week, Coroner David Ridley (left) chose to focus on Bradley’s hobby of online gaming. He was told that Bradley frequented online groups and watched videos which discussed methods of suicide. The coroner voiced his “concerns over the accessibility of online videos which focus on suicide and self harm.”

Friends and family described Bradley as a “smart and gifted student” who was “happy” and a “funny guy”.

A statement by Bradley’s mother Jenna, read by the coroner, said that Bradley was “sensitive” and thought he may have been on the autistic spectrum but had never been a formal diagnosis.

What is certain, however, is that Bradley was an exceptionally gifted mathematician. In 2017, along with some other pupils at Stonehenge School, he took part in a national challenge set by the United Kingdom Mathematics Trust (UKMT). Bradley (right) was awardedbest in school and went forward to the Junior Mathematical Olympiad where he achieved a merit.”

Jenna said her son seemed “happy and settled” before Christmas and was looking forward to going back to school. The inquest also heard that the teenager’s behaviour had changed prior to his death, and he had become more depressed and withdrawn. He had also spoken about killing himself to friends.

The coroner delivered a verdict of accidental death, concluding: “I am satisfied that he did not intend to take his own life. What concerns me about Brad’s case and the way children and young people, talk about social matters is the availability and access to such material on the internet it almost normalises something that is not normal.”


April 24 2019

On October 2nd 2017, 17-year-old student Marcelo Mulaba died when he stepped in front of a train at Bath Spa Station (left).

Born in Kenya, Marcelo came via Angola to Bath to live with his mother and step-father. In May 2017, he moved to West Lavington to live with his foster mother Eleanor Preston-Gill and her family. At the time of his death, he was studying music at the Bath Studio School.

His inquest this week heard that Marcelo had had a history of “mental health problems” since 2013 when he was first referred to CAMHS in Bath. He was discharged by CAMHS in April 2017. In the summer he was seen by GP Dr Kostelnik at Market Lavington Surgery, who prescribed antidepressants. The court was told that “initially the medication worked but later his mental health deteriorated”. Mrs Preston-Gill arranged for Marcelo to have counselling.

Delivering a verdict of suicide, coroner Dr Peter Harrowing criticised the lack of communication from Wiltshire and Bath Child and Adolescent Mental Health Services (CAMHS) and partner agencies, and their speed in making improvements after a serious case review, the conclusions of which have not yet been implemented.

After the hearing Mrs Preston-Gill said she was not happy with the way CAMHS had failed to tell her about Marcelo’s health problems, nor their lack of support for the family and Marcelo in 2017.


April 15 2019

On January 20th 2018, 22-year-old student James O’Shea (right) took his life in his room at a hall of residence in Cambridge University.

Today’s inquest heard that James returned home to live with his mother in the summer of 2017 after finishing a masters degree at Bristol University which left him feeling “depressed and increasingly low”. Deferring his post-graduate place at Cambridge until January 2018, he visited the local GP and was prescribed Citalopram.

James returned to the surgery in October when his mother Kate (left) was concerned that he might take his life. She said: “He would often hide how he was truly feeling to NHS staff and a private counsellor he was speaking to online. James was terrified of being sectioned. He made a good face to people. He would pour his heart out to me and then would come back and say that ‘I’m alright now’.”

Kate also told the court that it was clear that James was “burned out” when he returned from Bristol. She said: “He was seeking support. He spoke to GPs in the hope of getting some cognitive behavioural therapy. He was prescribed Citalopram, he took it sporadically. He grew more suicidal and we think he took an attempt on his life. It became clear that, as he took Citalopram, he became more demotivated and eventually took his own life.”

At this point, the report in the Daily Mail states: “Citalopram is a type of antidepressant often used to treat depression and also sometimes for panic attacks. Citalopram helps many people recover from depression.” This comment is not attributed to anybody at the inquest – it is not clear, therefore, whether it was actually stated at the inquest or whether it has been inserted by somebody at the newspaper.

James took up his place at Darwin College in January 2018, and was found dead later that month. Coroner David Heming (right) confirmed that James had taken his own life and that there was no third party involvement. He decided that it was not the prescription of Citalopram, but “it seems to be relationships with others which is the central issue.”


April 9 2019

On August 9th last year,  22-year-old student Max Davies (left) from Monmouth took his life while on a family holiday in Tuscany.

In last Friday’s KentOnline, Max’s mother Tracey said that the family is launching the Mindstep Foundation in memory of Max to help prevent further deaths.

Tracey (right, with Max) said that he was popular, funny and handsome. He thrived at sport, particularly rugby, and had no history of depression. While he was studying at Canterbury Christ Church University, he played for Canterbury Rugby Club.

However, Tracey noticed a difference in Max at the end of his second year: “He was very quiet, but he didn’t want to talk about it.” And when Max went home for Christmas in his third year: “He said he was feeling low but he didn’t know why. He said ‘I don’t understand why I feel like this’. That was far more distressing to him than anything. I realised this was bigger than us. We needed help.”

Max saw a psychologist who told Max that his mood was “caused by a chemical imbalance”. It is astonishing that a medical practitioner is still peddling this myth which has been exposed as nothing more than a marketing ploy fabricated by pharmaceutical companies a few decades ago. It is no surprise to discover that this unnamed psychologist thought it appropriate to prescribe antidepressants. From this point, Max’s mental health worsened and Tracey eventually brought him home from university.

Max’s family have already raised thousands of pounds for their Foundation, the aim of which is understanding, prevention and support through sports-themed workshops as well as funding research into clinical depression.

Tracey said: “We also want to look into funding more easily available support in places of learning, like schools and university. I think universities have to do more. If you look at a degree course, students have a lot of time on their own. There are deadlines, social life, alcohol, which is a depressant. Tutors need to have an eye for what to look out for.”

Tracey’s  goal in life is to prevent more deaths like Max’s. “This foundation is hopefully going to be something that goes beyond Max and me.”


March 17 2019

Yesterday’s Daily Express reported that Deborah Wastie is suing The Priory for alleged negligence after blaming staff for the self-inflicted death of her property developer husband in May 2015.

59-year-old Keith Hearn (left) was found hanged in his room while undergoing “treatment for depression” at the private hospital at Roehampton in south-west London.

In a statement of claim issued at the High Court, Deborah accuses staff of missing vital opportunities to prevent the father-of-two harming himself. She says he hanged himself with a bag strap that should have been removed when nurses searched his room. Her lawyers will also argue that, despite Keith’s being suicidal, staff ignored a senior consultant’s orders to keep him under one-to-one supervision. He took his life during a gap between checks which were carried out every 15 minutes.

After Keith’s inquest in April 2016, Deborah said: “In the Priory I believed he would be in the best place with medical experts who understood his condition. I was given every hope they could help him get better and return him to the Keith I knew. We are devastated by his loss and miss him every day. He was a warm, intelligent person and it was heartbreaking when he became ill. We tried to help him as much as we could, but in the end realised he needed professional care.”

The Priory’s owners plan to contest the claim, saying there was “a high probability Mr Hearn would have taken his own life anyway.”


March 8 2019

On October 28th 2018, hairdresser Natalie Hughes (right) was found by her ex-partner Sean Dawson hanged at her home in Wigan, after she had told him not to bring their four children back to her and he became concerned for her welfare. 11 weeks earlier, Natalie had separated from Sean after a 15-year relationship.

This week’s inquest heard from her GP Dr Madhu Pal, who said: “She was a 34-year-old woman who suffered from anxiety and she received Citalopram for this on January 17, 2018. She had been feeling anxious for 14 months and she was suffering from post-natal depression.”

Sean said: “During our separation, I resided in a different property. When she ran out of her Citalopram her mood changed, but she was back to normal after getting more medication.”

Delivering a verdict of suicide, coroner Rachel Syed (left) said: “Natalie was a loving mother who was doted on by her family but we heard evidence she suffered from anxiety and post-natal depression and was using Citalopram.”


March 4 2019

On February 2nd 2016, police were called to a house in Allerton Bywater, near Leeds. They found the bodies of Geraldine Newman (51), who had been hit with a hammer, as well as her two children, Shannon (11) and Shane (6), who had been stabbed multiple times. Later that day, the body of their father, 42-year-old Paul Newman, was found at the foot of cliffs at South Stack, Anglesey, nearly 300 km away.

Today’s inquest heard that, 17 years previously, Paul had proposed to Geraldine at South Stack. The court was also told that Geraldine and Paul had endured marital problems for years, and Geraldine had told the headteachers of their children’s schools that she was breaking up with Paul.

Paul suffered from a bad back and had been diagnosed with OCD, for which he had been prescribed antidepressants. He blamed the medication for the changes in his mood. A post-mortem found antidepressants and a very small amount of alcohol in his system.

Paul Johnson, who conducted a domestic homicide review, said that his findings were that: “Potential improvements can always be identified, but in this case there’s nothing to suggest, in my opinion, that would affect the outcome.”  He added: “It’s an absolute tragedy. I did try to find some rationale or reason, but I couldn’t.

Coroner Kevin McLoughlin (left) concluded that, despite a lengthy investigation, there were still no warning signs of the extreme violence that would occur at the home, and that Mr Newman had not expressed thoughts about wanting to harm his family. He recorded a verdict of unlawful killing for Geraldine, Shannon and Shane and a verdict of suicide for Paul’s death.


March 3 2019

In September last year, 16-year-old Lauren Pinnock (right) took her life by hanging at her home in Rainham, Essex. After last week’s inquest, her mother Laura spoke about the circumstances surrounding Lauren’s death to the local newspaper, saying: “Lauren had a heart of gold, she never isolated anyone and was loved by everyone; she really did walk into the room and make a mark.”

When she was 14, Lauren was diagnosed with polycystic ovarian syndrome (PCOS). Laura said: “She was given Yasmin (left), a contraceptive pill, that helped with PCOS, which has got a close link to suicidal tendencies, but when Lauren was taking them correctly her mood was extremely high.”

At 16, Lauren left school to pursue a career in hair and beauty, and on September 8th last year she was offered the job she wanted in a local salon. She was due to begin work on the following Wednesday but died on the Tuesday, shortly after she had texted her boyfriend to tell him she was having a bad day.

After hearing evidence at the inquest, coroner Nadia Persaud (right) recorded a verdict of suicide. She said: “Lauren was a 16-year-old girl, she was described by her family and friends as being loving, caring and as somebody who was always helping others. Lauren had suffered from polycystic ovaries. This is likely to have caused some hormonal disturbance and this was described as being a rollercoaster of hormones.

She was on medication for it but had not been taking them in the months leading up to her death and only started re-taking them seven days before she passed away.”

Yasmin is included in a list of “drugs that can trigger and cause suicide or homicide” compiled by Dr David Healy, one of the world’s leading psychopharmacologists.


March 1 2019

An inquest was held in Preston last week after the death of 29-year-old student Loran Atkinson (left). Loran, who lived in Preston and studied at the University of Central Lancashire, died on December 23rd 2017, after falling seven storeys from a balcony while on holiday in Malaga with her mother.

Loran’s mother Angela told the court that, historically, Christmas had been a challenging time for her daughter, so she had taken her to Spain for a break.

Coroner James Newman (right) said: “Loran had battled with mental illness for a period of time. She was on medication and appeared to have good insight into her condition.”

He continued: “For the first three days Loran appeared to have a good holiday. She was relaxed and enjoying herself. However, on December 23rd, it would appear that her anxieties drew to the fore again”.

The coroner concluded that Loran’s death had been “an act on the spur of the moment” which was “impossible to predict and impossible to prevent.” He did not mention the possibility that Loran’s “anxieties” and subsequent death could have been attributed to antidepressant-induced akathisia when he delivered a verdict of suicide.


February 24 2019

Yesterday, the Courts and Tribunals Judiciary published a selection of Prevention of Future Deaths Reports on their website. One of these referred to the inquest of 15-year-old Maximilien (Max) Kohler on October 3rd last year. Max had taken his life by hanging on May 5th 2018, in his bedroom at home in West London.

Coroner Fiona Wilcox (left) reported that Max, whom she described as being “very clever”, had been wrongly diagnosed with depression on two occasions when in fact he was “suffering with Autistic Spectrum Disorder.”

Dr Wilcox continued: “These diagnoses had at least in part been arrived at by the use of questionnaires. Expert evidence was taken and accepted by the court that the earlier misdiagnosis may have been contributed to by the latest fashion in mental health to over-rely on questionnaires and perhaps less upon clinical evaluation of the whole picture presented by the patient. It is possible that such over-reliance can contribute to misdiagnoses and underestimate risk.

The over-reliance on the use of questionnaires to assess the risk of self-harm, compared to full psychiatric history taking and evaluation of the patient in the round by a clinician with experience has been a repeated theme in inquests.”


February 13 2019

On May 29th last year, 56-year-old Richard Smith left his house early in the morning to take the family dog for a walk in the woods near Horncastle, Lincolnshire. Some time later, the dog returned home alone. Richard’s wife Elena went to look for her husband, and found him hanging in the woods.

Richard’s inquest, held at Boston Coroner’s Court (right) yesterday, heard that his family blamed the antidepressant drug Citalopram, prescribed less than two weeks earlier, after he complained of panic attacks brought on by increased anxiety.

In a prepared statement, Richard’s sister Angela said: “The family, siblings and parents believe that the prescription of the antidepressant drug Citalopram played a major part in Richard’s suicide. In fact, we believe that, had he not been prescribed this drug, he would still be with us today. We appreciate that the medical evidence shows that the drug was within normal levels in Richard’s bloodstream. However, we believe that this drug adversely affected Richard’s state of mind.” Angela added: “We wouldn’t want any other family – if there is anything that can be done – to go through the pain and distress we have had.”

“Expert evidence” given to the hearing by toxicologist Dr Stephen Morley (left) said there was evidence of an increased risk of suicide or suicidal ideation in the first month after starting antidepressants. Dr Morley concluded: “I’m unable to give a definitive answer as to whether Citalopram directly contributed to the increased risk of suicide in this case.”

Coroner Paul Smith recorded a conclusion of suicide.


February 13 2019

24-year-old student Jakub Guja (right) was born in Poland, but grew up in England. In October last year, he was found hanged in his room at Keele University.

At his inquest this week, his brother Michael said that Jakub had suffered from depression for a number of years and was struggling to engage with other students at university. The court was also told: “He was receiving help from mental health services and had been prescribed several types of antidepressant medication.”

Jakub was being supported by Deborah Boughey, Keele University’s mental health co-ordinator, who said in a statement: “Jakub contacted me saying he wanted some support. He mentioned suicide regularly – he was adamant he would kill himself one day.”

Choosing to ignore the over-prescription of antidepressants, coroner Sarah Murphy recorded a conclusion that Jakub had died by suicide, while suffering from psychotic depression. She added: “This was a tragedy for a young man who was obviously intelligent and had a bright future ahead of him. He tried to engage with mental health services which put many things in place. It’s very sad that he wasn’t able to improve and he made the decision to take his own life.”


February 8 2019

53-year-old Benny Thomas, his wife Jane and their family had been living in Spain for several years, but decided to return to Bristol in 2017. They bought a large house in Clifton, which needed substantial refurbishment. Benny became stressed by the process, and developed insomnia.

In November 2017, Benny told his GP that he felt at “rock bottom”, and was admitted to the local Priory Hospital (left) in Bristol on November 27th. He remained there as an inpatient until his death on January 2nd 2018.

At Benny’s inquest this week, consultant Dr Jon van Niekerk (right) said that Benny’s symptoms were “atypical for just a psychiatric diagnosis“. He added: “He had significant stress from the work done to the home. It seemed like an excessive guilt accompanied matters at the time. His memory and concentration were affected over a very short period of time. He complained of poor sleep, he seemed to be in a stupor. He had problems accessing memories and answering questions.” He was given a diagnosis of “severe depression and anxiety.”

The doctor continued: “He said he felt quite low in mood and didn’t think he was doing well. Mrs Thomas had reported he was paranoid about his medication. He didn’t have positive beliefs about it and thought they were harming him.”

Despite these paranoid thoughts, Benny was granted leave in the community so he could spend time with his family. As an informal patient, Benny could have three hours of unaccompanied leave outside the ward, eight hours accompanied and one hour on the grounds.

A few days later, Jane reported that her husband had developed paranoid thoughts. When his paranoia continued and he would not engage with therapists or take his medication, his risk level was raised to high.

The inquest was told that an improvement was noted a week later, with Benny in a better mood, less suspicious and taking his medication,.

In a formal mental health assessment, Dr Tan of the Priory told the court that Benny had “presented well, making eye contact and was calm and present“. He said he did not want to leave the hospital prematurely, wanted to get better and was willing to take his medication. Although his mood was low, Mr Thomas had told doctors that “life was worth living“.

Benny’s final meeting with doctors was on December 29, 2017, where it seemed that things were moving forward. He had been home for an hour at a time the two previous days.

At about 1:30pm on January 2nd 2018, Benny requested six hours of accompanied leave at about 1.30pm. He told a nurse he was going to town, and then going home with his wife.

Benny never returned to the Priory. CCTV showed that, four hours after leaving the premises, he arrived at nearby Stapleton Road Station (left). After spending over four hours at the station, he stepped in front of a train at 8:45pm.

The inquest had been told that at no point during his treatment had Mr Thomas expressed any desire to harm himself or take his own life.

Delivering a narrative conclusion, Coroner Robert Sowersby (right) said: “I am uncritical of the care Mr Thomas received at the Priory and I don’t think any different reaction to his non-appearance would or could have changed the outcome.”


February 1 2019

On July 26th 2017, 43-year-old Sarah Yassin (left) was found at the foot of cliffs at Seaford Head. This week’s inquest in Eastbourne heard that Sarah had been diagnosed with anxiety and depression in 2016, and had been prescribed antidepressants. In the months before her death, the dosage of her medication had been increased.

Sarah’s husband, Dr Richard Yassin, said that she had been a lively, energetic and loving person who loved keeping active and immersing herself in village life. He said in the time leading up to her death he had been regularly told friends that she seemed a lot better and was recovering. He told the court that he did not think depression was the only reason behind his wife’s death. He said: “I believe it was the high level of medication that made her take her own life.”

Consultant psychiatrist Richard Bowskill (right) said that, despite Mrs Yassin’s light weight, she was fit and healthy and able to sustain the dose of medication. He said she had shown positive signs of wanting to live and a desire to get better. He described her condition as “hormone induced depression” and said menopause depression is a recognised issue and a “biological depression.” He also said that Sarah had “a profound sense of shock that her body had let her down.”

Coroner Alan Craze (left) ruled that Sarah’s death was suicide. He said: “She did intend to take her own life. Here we can see that she left out all the letters and other legal documents.” There was no report of the coroner’s making any reference to Sarah’s heightened dosage of antidepressants.


January 31 2019

On March 29th last year, 16-year-old schoolgirl Rachel Denbow (right) was found hanged in Newton Abbot. An inquest in Torquay yesterday heard that she phoned her friends during the evening telling them what she intended to do. It was her friends who found her near the quay in the town.

The court was told that Rachel had been “treated for emotional distress.” Her mother Jacqueline said that the pressure of taking exams at school had led to panic attacks and stress, and that she had also been upset after a close friend had taken an overdose in a suicide attempt in January 2018. However, after some problems at college, she had seemed better and more positive.

Coroner Ian Arrow said that he would record Rachel’s death as having been self-inflicted.


January 15 2019

18-year-old Robin Brooks (left) had finished a course at a college in Cheshire, and was due to start an apprenticeship so he could train as an electrician. In the meantime, he was doing some work at a quarry near Macclesfield, helping out with odd jobs, when he was found hanged in a storage area on August 14th last year.

At his inquest yesterday, Robin was described as “smart, adventurous and caring” with a bright future ahead of him. But he had also been showing signs of depression and his family persuaded him to seek help from his doctor. His father told the court that, after seeing his doctor and being prescribed medication, he seemed to be responding positively.

Coroner Heath Westerman delivered a verdict of suicide.


December 14 2018

In August 2017, 15-year-old Mia Bell (right) was found hanged in woodland near her home in Derbyshire, in the same spot where her father had taken his own life when she was six. Her inquest in Chesterfield this week heard that Mia had been an outgoing and happy child until her father’s death. She regularly visited the spot, leaving flowers and notes.

Chris Kirk (left), lead nurse for Derbyshire CAMHS, told the inquest: “Mia was a very pleasant young lady who had been through some difficult times emotionally…We were looking at ways of helping her cope and, to my mind, things seemed to be getting better.”

Coroner Peter Nieto concluded that Mia had “undertaken a deliberate act”. He added: “She had chosen the place of her father’s death and his death clearly preoccupied her.”


December 10 2018

Sky News reported yesterday that the family of 29-year-old Aidan Knight (right) have won a six-figure payout after Sussex Partnership NHS Foundation Trust admitted a catalogue of failings in his care. His three children have been awarded the financial settlement, to be split between them after lawyers brought a civil action against the trust in the High Court.

Aidan joined the army when he was 17 and within two years was on a six-month tour of duty in Iraq. He left after five years, telling his mother that he had seen “too much death“. He also struggled to cope with the loss of his brother George in 2012.

In 2014, Aidan took an overdose in the first of four bids to end his life. During this time his GP had prescribed him antidepressants for his erratic behaviour. Despite assessments by police and NHS psychiatrists recording that he had symptoms of post-traumatic stress disorder (PTSD), he was not considered high risk enough to be admitted to hospital.

On March 5th 2015, Aiden attended the accident and emergency department at East Surrey Hospital. A psychiatric nurse diagnosed PTSD symptoms and five days later the community mental health team assessed him. It was not until March 26th that his referral to a mental health practitioner was confirmed, but his mental health practitioner was on holiday until April 8th and he was not reassigned to another case worker. That was the day Aidan was found hanged in a park in Crawley, West Sussex – the day before what would have been his brother’s birthday.

At his inquest in 2017, coroner concluded that his death was a suicide and a serious incident mental health review admitted that the trust should have done more for Aidan.

Aidan’s mother, Angie Aleksejuk (55), said: “I wish that just one person had thought differently in the period leading up to Aidan’s death, as if they had he may still be here. He ticked all the boxes of being at risk – a former serviceman, under 30, he had lost his brother, lived alone and he even presented himself to A&E – but he slipped through the net. What happened has devastated our family. This was never about getting compensation but getting the trust to apologise for their failings in Aidan’s care.”


December 5 2018

On August 6th this year, 41-year-old Vicki Archer (left), a presenter on BBC Radio Shropshire, left her show mid-way through after telling colleagues she was upset. She drove home and, some hours later, she was found hanged in her loft.

At yesterday’s inquest, a statement from the family read: “We still cannot believe that Vicki’s not here. Her zest for life was infectious, she was a wonderful mother and daughter and her charm brought a smile to all those who knew her. She could light up a room. While we will always miss her we want to remember and celebrate everything that she achieved which is why in the spring we are planning a memorial celebration of her life. But in the meantime we want to thank everyone for their support and kindness helping us through our immeasurable loss.”

Coroner John Ellery (right) told the court that Vicki suffered from depression, and that medication was found in her system. He concluded that the she had intended to take her own life, and delivered a verdict of suicide. He added: “This is a tragic case for the family, and our thoughts are and must be with her children.”


November 29 2018

On June 23rd this year, 58-year-old Lucy Birley (left) shot herself while staying at the home of her brother in New Quay, Co. Clare. Lucy was best-known for being married to musician Bryan Ferry from 1982 to 2003. Together they had four sons.

At her inquest in Ennis this week, coroner Isobel O’Dea (right) told the court that “the post mortem report showed that Ms Birley had very little alcohol in her system and a therapeutic level of antidepressant medication.”

In her conclusion, the coroner said: “I am satisfied that Lucy took her own life. She left notes there.”


November 28 2018

On January 22nd this year, 16-year-old William Jordan (left) was found hanged in his room by staff of the Priory Hospital in North London. He died in hospital the following day.

William was admitted to the Priory after being diagnosed with “long-term depression” while he was a pupil at Berkhamsted School, in Hertfordshire, where he had captained the rugby and football teams.

This week’s inquest heard that, days before he died, William had told his consultant psychiatrist that he was worried about the lack of staff observation. He was, in fact, left unattended in the hours leading up to his death, despite clear instructions that he required checking four times each hour. After William’s death, members of staff then falsified logs to appear as if they had done so.

Safety concerns had been raised about the hospital in 2016 when government inspectors found a high risk of ligature points in all wards. A report, published by the Care Quality Commission (CQC) in July, concluded that the problem was still acute, particularly on child and adolescent wards. CQC Officials documented concerns about the child and adolescent wards, including unsafe levels of staffing, inadequate training and ineffective monitoring of vulnerable patients.

Coroner Andrew Walker (right) said that there had been “a really serious failure by the staff who came upon William that they did not immediately go to his assistance” until a doctor arrived. He added: “Entries in the observation log were entered to create the impression that the observation has been carried out.”

The Times, the only local or national newspaper to report on William’s inquest, did not mention any details of the medication prescribed to William during his stay. What the report did reveal was that “the Priory Group has become the largest mental health provider in Britain. It receives tens of million of pounds in NHS contracts to care for non-private patients. However, safety concerns have been raised after a series of deaths.” Some of those deaths are mentioned in my article Treated at the Priory.


November 17 2018

On May 2nd this year, 18-year-old Rose Chambers (left) was found in a wooded area in Shrewsbury. Her inquest this week was told that Rose had been declared missing after failing to return from work, and her mother was concerned about items she had found at her home.

Rose was studying at a college in South Wales when she was prescribed Fluoxetine by Dr Anne Alison, from the Cowbridge and Vale Medical Practice.

At the inquest, Dr Alison was questioned by Rose’s family solicitor Jamie Gamble (right) about the side effects of the drug that caused her mood to drop after taking it. The GP replied that it was normal to struggle to begin with, but then the side effects would level out.

Mr Gamble also questioned Sandra Hayman of the Severn Fields Health Village in Shrewsbury as to why there was a six-month wait up until her death for psychotherapy, and she said the current wait is six to ten months.

A mental health nurse from the Shropshire crisis team, Helen Jones, said that, on April 30th, Rose told her repeatedly that she planned to kill herself:  “She didn’t feel she was being taken seriously. She said she would kill herself later that night or at some point the following day.” Miss Jones arranged for Rose to talk with night staff at 11pm that evening, and believed Rose would keep herself safe. However, she said due to her making plans for the future, she didn’t think she was actively suicidal.

Mr Gamble also questioned further why there was no mention on a review report following Rose’s death, about the claims she wanted to kill herself. He added that the family believe there are discrepancies in the evidence of another witness who was too ill to attend, and coroner John Ellery (left) adjourned the inquest until December 17th to obtain answers from the witness.


November 17 2018

Earlier this week, I went to a meeting in Prestatyn, North Wales, hosted by Shane Cooke and his mother Mary. Also present was Dr David Healy (right), who had accepted an invitation to speak at the meeting.

Yesterday’s Rhyl Journal reported on Shane’s attempts create a support group for people adjusting to life after prescription medication.

Shane (38) was inspired to create the group after attending a Hearing Voices meeting in Wrexham, which supported his own transition off a course of treatment, and finding that there was no equivalent closer to home. He had previously been prescribed a variety of courses of medication

Shane (left) said: “There’s hardly any support or information in the area, it seems to be pretty much absent everywhere in Denbighshire. Sometimes the move off medication can be worse than the original condition and it can be a long road to recovery, you can gain weight and lose your motivation to do anything for anything up to a few weeks to a few months. I don’t think I had pictured how long this journey would take or how difficult it would prove to be, that feeling of being part of the human race again is well worth waiting for.”

The motto of his newly-formed peer-support group is “Better Times Will Return”, and he has written a booklet about his experiences for others to share.

Shane added: “You have to be very careful, as each person is different, so we don’t offer any medical advice – just support. However, people can share what worked for them. The group will also support families, because it can also be very difficult when you need extra care and it can be very difficult to see a loved one go through this. I’m just trying to let people let people know that there is something there if they need help coping with the withdrawals and side effects.”

The group meets every two weeks at Nant Hall Road Church, with the next session taking place on Tuesday, November 27 from 6.30pm.


November 15 2018

Following his inquest this week, Brian Lee (right) was described by the Daily Mail as an 80-year-old millionaire former dentist. On May 24th this year, Brian was found drowned in his bath at his home in Marlow, Buckinghamshire.

An almost-empty bottle of brandy was found in the bathroom, as well as an empty blister pack of Zopiclone.

The court heard that Brian had left several notes in which he had talked about his intention to take his life, writing: “I can’t take any more. So sorry.”

Brian had diabetes and also had been suffering recently with “insomnia and night terrors, believed to be linked to his Prozac (Fluoxetine) medication.” A friend told the inquest that Brian left a message on his phone on the evening before he was found : “Brian had seen his doctor who had taken him off Prozac. He felt devastated and was unable to get anything done. He asked me to say a prayer for him.”

Coroner Crispin Butler (left) recorded the verdict as suicide and said: “There are notes and messages which we have heard in evidence from a number of sources all of which confirm Brian’s intention to take his life.”


November 14 2018

On August 8th this year, 32-year-old art teacher Daniel Phipps (right) was found hanged in woods in Westdene, Brighton. His inquest this week heard that Daniel had been struggling to cope with a relationship break down a year earlier.

In April this year, Daniel went to see his GP, Dr Sally Howlett, at the Albion Street Surgery. He was prescribed antidepressants and referred to the East Brighton Treatment Service. Dr Howlett told the inquest: “I was very shocked when I heard about his death. I had the impression that while he still had suicidal thoughts, he was still processing them logically. His medication was increased and he seemed quite logical about how he was going to get better. He was attending all his appointments and was keen to engage with us.”

Coroner Catharine Palmer asked Dr Howlett whether it was possible that Daniel had simply become suddenly overwhelmed by his low mood. The GP’s reply was that he was made aware of where he could find emergency mental health treatment if he needed it.

In her conclusion, the coroner said: “On the face of it it seems Daniel was referred to mental health services and was seen pretty quickly by them. The overall impression I get is that although he perhaps still had suicidal thoughts, they were improving.” The coroner chose to ignore the possibility that an increase in Daniel’s medication may have been involved.


October 24 2018

An inquest in Maidstone yesterday heard that 15-year-old schoolboy James Corcoran (left) was found hanged at his home in Yalding on June 16th this year. James, who was a pupil at Mascalls Academy in Paddock Wood, was described as “characterful, charming, and popular”.

Concerns for “normally happy” James had first been raised in October last year. He was recommended by his school for a wellbeing programme but stopped attending after the first session. In March 2018 he told staff he was feeling low and he was referred to Kent Community Health NHS Foundation Trust.

James’s mood continued to deteriorate and, in the days leading up to his death, friends said he had been lying on the floor of the school bus listening to sad music and had become withdrawn.

Coroner Ian Wade (right) did not reveal the reasons for James’s low mood, but said: “I am aware of certain matters that I’m perfectly sure would have caused him great anguish and upset. It seems to me that there are many reasons we might regard him as in turmoil and tumultuous events in his life were causing him distress. He was having trouble adjusting to crises in life but he was the object of caring attention. Right across the board he was plainly looked after at home. The school was taking steps.”

In the days leading up to his death, friends said he had been lying on the floor of the school bus listening to sad music and became withdrawn.

Mr Wade concluded that James had taken his life, adding: “There is nothing more that any of us can do but share our sympathy and condolences. I hope that James is remembered for the lovely, lively little boy that he was.”

This year, Maidstone Coroner’s Court has been the venue for the inquests of at least two other school pupils from the same part of Kent. Brandon Warren (14) and Edward Ketchen (17) both died by hanging.


October 11 2018

Yesterday’s Scottish Sun included an article which revealed that a psychiatrist prescribed Prozac (Fluoxetine) to an 8-year-old schoolboy.

Sharon McCann (left), from Banchory, Aberdeenshire, said that her son had been “showing signs of anxiety from a young age, with group therapy sessions failing to have any effect on his wellbeing.” She added that her son’s condition “can make him reluctant to attend school, causes low self-esteem and limits his ability to mix with others.”

When Sharon took her son to attend an appointment with an unnamed psychiatrist, she was “shocked and saddened” when he prescribed Prozac because he said there was “nothing more he could do” for the schoolboy.

Sharon refused the prescription, feeling that it was “not appropriate” due to her son’s age, and the incident compelled her to campaign for better mental health treatment for children.

In fact, the prescription would have been inappropriate for a fully grown adult, as there was no suggestion that the patient was suffering from the “moderate to severe depression” which NICE states reaches the threshold for giving antidepressants to adults.

Sharon said: “For me this felt like a pivotal moment as I realised the importance and urgency of providing earlier mental health intervention. I believe the answer is in our primary schools, which are really struggling to know how to support children with problems like this as they don’t have the resources or specialists. By the time children reach secondary school, their problems could have become much worse if they have not been picked up on.”

She added: “Anxiety, and other mental health problems, can have a huge impact on children’s lives and learning. This is sensitive and personal but I want my voice to be heard for my son – and others like him.”

Her son is now receiving one-to-one sessions with a psychiatrist.


September 25 2018

In July last year, 22-year-old nurse Clara Malagon (right) was found hanged at her flat in Manchester. Clara worked at Manchester Royal Infirmary, where, in May 2017, she was on duty during the night of the atrocity at Manchester Arena.

Yesterday’s inquest heard that Clara had suffered low moods and had been prescribed Citalopram while studying for her degree in nursing at the University of Manchester. She was on the drug for about 6-7 months before stopping in September 2016 and finishing her nursing degree.

After the atrocity, Clara underwent counselling and had a detailed debrief with senior doctors. But, weeks later, she told her flatmate that she had made an appointment with her doctor to prescribe some more antidepressants.

A statement from Clara’s GP said: “She was anxious about work, she had her own self doubt and confidence issues and she said she wasn’t sleeping. But she denied any suicidal thoughts. She said she wanted some medication.”

Recording a conclusion of suicide at a hearing in Manchester on Monday, Coroner Andrew Bridgman (left) said: “Clara did intend to take her life but this inquest cannot answer whyThere appears to be no reason and no evidence as to why Clara had depression and was in a low ebb when she wished to take her own life. She had been supported by her father, her family and her friends. It’s a real tragedy.”


September 18 2018

An excellent article by Katinka Blackford Newman (right), entitled ‘How we’ve hooked a generation of children on depression pills they don’t need”, is now available at MailOnline.

Katinka discovered that more children than ever are now being prescribed antidepressants, with almost a million prescriptions being issued in the past three years. This figure includes an astonishing rise of 24% to children under 12.

Katinka’s article includes an interview with Tracey Key, the mother of 17-year-old Reece (left), who took his life after suffering akathisia induced by Sertraline, which he had been prescribed the previous week in contravention of NICE Guidelines, and without his mother’s knowledge.

Child psychiatrist Professor Sami Timimi (right) told Katinka that he prescribes antidepressants “only when patients or their parents insist.” He added: “I explain that the drugs double the risk of suicidal intention in adolescents and are no more helpful than a placebo. The other issue that patients are not aware of is how hard it is to come off these drugs.”

David Healy (left), a professor of psychiatry, believes these drugs are responsible “not just for suicides, but also episodes of violence.” David believes that we are not seeing the full picture because “most of the research has been cherry-picked to exaggerate the benefits, with only the drug companies having access to the trial data.”

Sami is concerned that: ”By offering medication, we are embedding the idea in teenagers that there is something wrong with them, whereas, in fact, they are usually reacting normally to difficult events in their lives. Depression is not an illness, it’s a state of mind. The problem with medicalised therapy is that it’s ‘one size fits all’. Human beings are more complex.”


September 6 2018

Earlier today, an inquest heard that 46-year-old Irish singer and musician Dolores O’Riordan (left) died by drowning in her bath while she was staying at the Hilton Hotel in London.

A post-mortem found that she had drunk a quantity of champagne and some spirits from the minibar. There was also an “above therapeutic amount of a prescription drug”, as well as therapeutic levels of other medication in her system.

The inquest heard that Dolores was on “a number of prescription drugs” since being given a diagnosis of bipolar disorder by Robert Hirschfeld (right), a New York psychiatrist. Her doctor, Seamus O’Ceallaigh, said that she may have had “an episode of mania or elevated mood“.

After hearing the evidence, Coroner Dr Shirley Radcliffe said: “Dolores O’Riordan was a hugely successful singer with a very supportive family and children; clearly much loved by many people. She had a shortish history of bipolar which she sought treatment for, but it would seem she had no significant relapse of mental health…There was no evidence that this anything other than an accident.”

(The following day, the paper version of the Daily Mail reported that Dolores was taking “three types of prescription medication to treat her depressive condition”)


September 2 2018

A week ago, on Sunday August 26th, 24-year-old David Katz (left) from Baltimore was taking part in a video games competition in Jacksonville, Florida. Apparently, David was not doing too well, and he shot at other competitors. 2 were killed and 9 more injured before David shot himself.

On Wednesday, the Daily Mail revealed that in 2007, when he was 13, David was taken by his mother Elizabeth to “doctors who prescribed Prozac and an anti-psychotic called Risperdal”. At the time, Elizabeth and David’s father Richard were undergoing divorce proceedings

A court record (click to enlarge) shows that Richard was bitterly opposed to psychotropic medication being prescribed, not only to David, but to their other son Brandon, who was 17 at the time of the divorce.

Perhaps the most extraordinary fact is that Elizabeth, who held a Ph.D in toxicology, was actually working for the US Food and Drug Administration (FDA) at the time of the divorce. One of the responsibilities of the FDA is to regulate the prescription of psychotropic medication.

In the years that followed, David was hospitalised twice in psychiatric units, had 26 police visits to his family home and was deemed by a psychologist to have a capacity for violence. Despite this record, he was able to buy a gun legally from a dealer in Baltimore.


August 10 2018

On April 10th this year, 35-year-old actor Alex Beckett (left), whose first name was actually Peter, was found hanged in a flat in Croydon, South London. Alex did most of his acting on the stage, but also appeared in the BBC TV comedy series “2012” and “W1A”.

This week’s inquest heard that Alex had recently ended a relationship, and police officers went to where he was staying after his ex-girlfriend alerted the police to a message she had received from him.

Alex’s medical records indicated that, towards the end of 2017, he attended his GP surgery, seeking treatment for depression. He had been taking antidepressants since that time. The dosage had been increased after he reported to his GP that they were having no effect on his low moods.

Coroner Sarah Ormond-Walsh ruled that Alex had died by suicide.


July 31 2018

On May 30th 2015, 18-year-old art student Isabella Finnigan (right) was found hanged in her room in a hall of residence at Manchester Metropolitan University.

The previous evening, she had been arguing with her ex-boyfriend about arrangements for a trip that he had made, and had sent him a series of texts. He switched off his phone but, the following morning, he picked up a voicemail from Isabella saying that she was going to kill herself.

Yesterday’s inquest in Manchester was told that Isabella, from Birmingham, had been studying an Art foundation course and was described as “passionate, talented and beautiful” by her family and friends. But she had been battling depression. She had been prescribed antidepressants and had been seeing a counsellor.

Isabella’s mother Siew Yap said: “Isabella was a happy child with no significant illness, but when she was about 16 or 17 she started college and she seemed withdrawn and wasn’t very communicative – her behaviour changed. I suspected it was part of her growing up but later on she told me she was feeling unwell and she was seeing a counsellor at college. She was prescribed medication and I wanted to go with her to the GP but she wanted to go on her own and I was very concerned about that because at the time she was still a child.”

Dr Abigail Rathbone, one of three GPs who saw Isabella, said she had “fleeting thoughts daily of harming herself.” The GP prescribed Fluoxetine and advised her to refer herself to the Birmingham Healthy Minds service. She added: “I would have been very much for involving parents and I would have advised her to discuss her symptoms with her parents and bring them to future consultations. I would not have been able to speak to her parents because of confidentiality.”

Recording a conclusion of suicide, coroner Zak Golombeck (left) said: “She was strong, well-articulated and intelligent and her death has highlighted many things – one of those things is that mental health amongst young people is very real. No blame will be passed on individuals and there is no blame on part of the GPs.”


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