Toxicology: Missing in Action



NicholasRheinberg1The most widely reported inquest in recent years was that of the well-known and popular international football player and manager Gary Speed (above), who hanged himself at home in November 2011. At the inquest, we were told that Mr Speed was just over the drink-drive limit, but Cheshire coroner Nicholas Rheinberg (right) chose not to reveal whether or not there were prescription drugs in his system.


MichaelAtherton1On New Year’s Day 2012, taxi driver Michael Atherton, 42 (left), shot himself, his partner Susan McGoldrick, her sister Alison Turnbull and Ms Turnbull’s daughter Tanya.

Earlier this month, the inquest pertaining to this high-profile “murder-suicide” was reported nationally as well as locally.


All the reports homed in on the flawed process by which firearms are licensed, with coroner Andrew Tweddle (right) calling for a radical overhaul.

However, the media struggled to give the public the reasons why this tragedy happened. The nearest we got to a reason was that Mr Atherton disliked his partner’s sister; hardly sufficient reason for such an extreme act.

The pathologist revealed that the amount of alcohol in Mr Atherton’s body was the equivalent of being one-and-a-half times the drink drive limit. So he wasn’t exactly intoxicated. But if there was anything else in his system, Mr Tweddle opted not to mention it. We do not know if Mr Atherton was under the influence of antidepressants or any other mind-bending medication.


WarrenGrier1The previous week, Mr Tweddle had conducted the inquest of barrister Warren Grier, 46 (left), who had hanged himself.

A police officer told the court that Mr Grier “was under financial pressure relating to a business venture”, and the court also heard that “a post-mortem confirmed he died from asphyxiation, with no trace of drugs or alcohol in his system.” When the word “drugs” is used in this context, it usually refers to recreational drugs, not prescribed medication. Here again, Mr Tweddle has failed to reveal whether a victim was driven to suicide by medication.


Around the same time, the inquest of police officer Andrea Shelton, 45, was carried out by coroner David Hinchliff in Yorkshire. Mrs Shelton was suffering from work-based stress. She went on to self-harm at home and was taken to hospital. After being transferred to another hospital, Mrs Shelton hanged herself in the shower. It seems highly unlikely that Mrs Shelton was not medicated in some way during this time. Yet Mr Hinchliff failed to reveal her recent medical history.


DavidHinchcliffDavid Hinchliff (right) also conducted the double suicide of Mr & Mrs Hainsworth, who attempted to kill themselves by breathing in carbon monoxide from a barbecue. Mrs Hainsworth died, but her husband regained consciousness and hanged himself. On this occasion, the court was told that “a post-mortem examination found both had alcohol in their blood and were about twice the legal drink-drive limit at the time of their death. They had also taken some medication.” But the type(s) of medication remained unreported.


Another inquest that took place this month was that of postman Graham Jenkins, 49, who hanged himself in Pembrokeshire. The local newspaper reveals neither possible motive nor any history of depression. In fact, the GP is not even mentioned. Returning a narrative verdict, coroner Mr Lewis said: “His intention remains unclear.” Mr Jenkins’s intention, or at least his state of mind, may have been made clearer had Mr Lewis mentioned toxicology findings.


DavidHealyProfessor David Healy (right), perhaps the world’s leading expert on adverse drug reaction, states that he has been writing to UK coroners for 15 years making the case that they should note where people have been on antidepressant or other drugs at the time of death. Yet in the past few months I seem to be finding a growing number of inquest reports where relevant toxicology is completely missing.

Is this a trend, rather than a coincidence, and if so what is the reason for it? In these days of austerity, are toxicology reports being omitted to save money? Or is there a political reason why bereaved families (as well as the general public via the media) are not being given the complete picture?


Update (28 March 2013):

RobinBalmain3Robin Balmain (left), the coroner for the Black Country, said two days ago that he had suffered his darkest day in a 40-year career after hearing five inquests into people who had hanged themselves in the space of one morning. Sitting at Walsall Manor Hospital, he said that all five people – aged between 33 and 54 – had killed themselves.

He also said, “I don’t know what the explanation is.”

There may well have been an explanation, or at least a clue, in the toxicology reports, but in the newspaper there is no mention of toxicological findings in any of the five inquests.


Related Articles

Failed in Furness

One town, two tragedies

Coroner’s Progress 1 (Ian Smith)

Coroner’s Progress 2 (William Armstrong)

Coroner’s Progress 3 (Geraint Williams)

Coroner’s Progress 4 (Robin Balmain)

What the coroners say: Part 1 (2003)

What the coroners say: Part 2 (2004-2005)

What the coroners say: Part 3 (2006-2008)

What the coroners say: Part 4 (2009-2012)

The Scientist, the Doctor and the Coroner

Under the Coroner’s Carpet

In the Court of the Coroner


8 Replies to “Toxicology: Missing in Action”

  1. Hi Brian. As you know, I had to insist on 2 toxicology tests before it was found my son had an SSRI in his blood when he killed himself. I am advised by our government scientists that following this, they were instructed NOT to conduct testing for any prescription drugs unless specifically ordered to by the Coroner. At best this is a terribly misplaced effort to reduce costs at worst an effort to cover up the role of prescription drugs in inducing suicide.

    • Thanks for your comment, Maria. Unless the cause of death is an overdose of medication, it is significant that when the involvement of antidepressants is mentioned at an inquest, it is much more likely to be the family who raises it, rather than the pathologist or the coroner.

  2. Coroners are, more than likely, of the opinion that these drugs do not cause people to carry out suicide. Their opinions need to change – pretty hard though seeing as the majority of them think they are God.

    • Hi Fid. I don’t know if the coroners themselves may be under pressure – see the article on Ian Smith. Some of the reports make it seem as if they have to do verbal gymnastics to avoid using the A-word.

  3. With a family member of mine in the U.S. I had to pay out of pocket for the toxicology screening post mortem. I would really like it if we could get legislation to insure that toxicology screens were done on all suicides but I am sure it is an uphill battle in any country. I am at least glad I am not the only one who thinks this would be a very good thing to do.

    • Thank you for making contact. I’m in total agreement, Toni. Toxicology must be regarded as crucial, and so we have to keep fighting to see that this becomes the case.

  4. I was given paxil 10 years ago for a sore arm from keyboard use , told it would help my arm …..10 drug addicted years later and many failed attempts to quit ..with a sore arm aomehow morphing into a drug induced mental illness ….never smoked taken drugs or had any psych issues before this in my life … until I tried to get of paroxetine/paxil .
    To say it was a traumatizing nightmare is an understatement. During my 9 month clueless taper and the next 2 years drug free I experienced horrific drug induced suicidal ideations…..first it tried to get me to cut my wrists then for months tried to get me to hang myself then shoot myself then I became fixated on crashing the car and wanting to jump of a bridge. It was a daily fight to stay alive but its a miracle i’m still alive.
    I’m 50 so perhaps they should change the age limit for the black box warning to 50 yrs.
    This drug is a mental thalidomide and the medical profession are an absolute shameful disgrace…..I have now stabilized only to discover my bodys testosterone level has fallen off the scale and im now chemically castrated suffering chronic fatigue …I used to be an athlete.
    Words cannot describe the humiliation, anger and total disbelief I now experience.

    • Mark’s story, which he has so courageously shared with us here, is a total indictment of the dreadful harm that Paroxetine/Paxil/Seroxat has caused down the years. So many have profited from producing and prescribing this terrible drug, regardless of the harm they have caused. Denial can no longer be an option for them; hopefully increasing awareness will lead to proper accountability.
      With thanks to Mark, and utmost respect.

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