News File: 2020


December 17 2020

On August 23rd this year, 25-year-old Charlie Mott (left) was found fully clothed in a shower at a friend’s house in Chalfont St Giles, with the shower hose entwined round his neck. Paramedics were summoned, but were unable to revive him.

Charlie was a researcher and assistant producer for BBC’s The One Show, and was described by host Alex Jones as “hugely talented and such good company.”

In a statement read out at his inquest earlier this week, a friend said that Charlie had been “on good form” that evening, adding: “We were all playing games and laughing a lot.”

Another friend said that, although Charlie had been on antidepressants, he “seemed very happy” during the day and they all spent the evening listening to music in the garden and drinking alcohol. He added that Charlie went from “happy to sad, back to happy again” during the night, but that was not unusual behaviour for him when he had been drinking.

Records from Charlie’s GP confirmed he had been prescribed Sertraline and, in a consultation the previous month, had said that he was finding them useful and wanted to continue taking them.

A post-mortem found that his death was as a result of hanging. Coroner Crispin Butler (right) recorded an open conclusion, saying that it was not clear if Charlie had intended to end his own life that evening or if his death was a tragic accident as a result of a slip while intoxicated. He did not mention the possibility that the combination of Sertraline and alcohol may well have induced akathisia.


November 27 2020

On February 24th this year, 29-year-old Dr Alicia Pylypczuk (left) was found hanged in her flat in Manchester.

This week’s inquest heard Alicia described as “talented musically and academically”. As well as working as an A&E doctor, she had been lead cellist in the Junior Royal Northern College of Music.

A statement from Alicia’s mother revealed that she had been diagnosed with alopecia when she was 17, and had been prescribed medication for anxiety and depression.

A statement from Alicia’s lodger mentioned that he was aware she had been signed off work for two weeks in January and that she had been given antidepressants.

Coroner Zak Golombeck (right) told the hearing how the dosage of her prescription was doubled from January to February. In his conclusion, he said: “The loss of someone so young, who has worked so hard to become a doctor and help other people is nothing else but a loss to society, but that loss is eclipsed by the loss felt by her family and friends who loved her.

“The medical cause of her death was hanging. I conclude that she took her own life with the intention to do so. To all those who have attended today I offer you my condolences and of course those must be extended to those who have not been able to attend today.”

The coroner did not mention that the risk of suicide is increased if the dosage of antidepressants is increased.


October 19 2020

Today, a Report to Prevent Future Deaths was published, following the inquest of 19-year-old Alana Cutland (left).

At the time of her death, Alana, who was a student at Cambridge University, was carrying out research on the island of Madagascar.

She was travelling as a passenger from Anjajavay to Antananarivo in a light aeroplane, when she opened a door and fell to her death.

In the PFD Report, coroner Tom Osborne (right) expressed his concerns: “The deceased was prescribed Doxycycline as an anti-malarial medication for use whilst in Madagascar. It was quite apparent from the evidence that she had a psychotic reaction as a result of taking the drug and yet there is nothing on the drug information leaflet that either highlights or mentions this possibility. If she or her parents had been aware of this possible side-effect they may have been able to intervene earlier to avoid her death. In my view the information sent out with the drug should be reviewed.”

Doxycycline can also be prescribed as an anti-biotic. Other anti-malarial medications such as Larium (Mefloquine) are noted for violent or troubling side-effects.


October 14 2020

Earlier this week, the inquest of 34-year-old Martin Rich (left) was held in Cleethorpes.

Martin, who was a chef, fell to his death from the balcony of his hotel in Athens while on holiday with his co-workers and his partner, Elizabeth Lakic, in October 2018.

The inquest heard how Martin  had returned to his hotel room with his partner following an argument during a night out with his co-workers. The argument continued and Martin left the room to go for a cigarette. When he returned, he threatened to jump from the balcony, and made his way there despite Elizabeth’s attempt to stop him. After climbing over the balcony’s fence, he sadly fell to his death.

A post-mortem found that Martin had an amount of alcohol in his system which was over double the limit for driving. He also had the antidepressant, Citalopram, present in his blood and urine.

Martin’s ex-wife told the inquest that Martin had started taking antidepressants after the death of his sister in 2017, “but not for long.” She added: “I know Martin was prescribed antidepressants once more but he did not want to stay on because it meant he couldn’t drink.”

The court also heard that, in the month prior to his death, Martin had visited his GP “to get help with his depression.”

Concluding the inquest, coroner Mark Kendall was unable to determine if Martin had deliberately intended to end his life or if it was accidental. He said: “The difficulty I have is that Mr Rich was in drink, and the nature of his behaviour has happened before when he was in drink. It is because of this I cannot conclude it was intentional suicide, as he may have tried to do it as part of his attention seeking, and sadly fell to his death.

It is because of this that I have to put it as an open conclusion, as I cannot decide between the two possible causes of death.”

The coroner did not mention the strong link between Citalopram and akathisia, which may well have been a considerable factor in determining Martin’s fatal actions.


October 08 2020

On May 18th this year, 32-year-old Dr Gareth Davies was found dead at his home in Burton, Staffordshire.

At his inquest this week, Coroner Andrew Haigh (right) said: “I’ve been told that Gareth was only 32 when he died. He was a young man who had achieved a lot in his life. He had qualified as a scuba diver and a doctor…In terms of attendance for his health, he sees his GP in February and is prescribed antidepressants. In early March his condition seems to be improving.

“Gareth was working as a GP at a different practice, working the weekend of May 16 and 17. There were no concerns about his work. On May 18 he does not attend work and that’s immediately a concern and enquiries are made. It remains unclear why Gareth decided to do this.”

The coroner concluded that Gareth “died from asphyxiation and ruled that his death was the result of suicide.”


October 05 2020

On February 8th this year, 20-year-old student Shubamso Pul (left) took his life in his room at the University of Sussex.

Last week his inquest was held in Brighton, where the court was told that Shubamso had attended a walk-in clinic in December last year where he discussed his mental health and was referred to a doctor.

He visited a GP and was prescribed antidepressant medication, with his dose being raised after four weeks when he described his symptoms as having worsened.

Concluding that Shubamso took his own life, coroner Veronica Hamilton-Deeley (right) praised the processes in place to support students, but said that lessons could still be learned from Shubamso’s death. She suggested that his flatmates start a support group, so that if “something like this happens again” then they could speak with those affected and help them through the experience.

She did not suggest that when a patient feels worse rather than better after being prescribed antidepressants, increasing the dosage is not necessarily the best course of action.


October 05 2020

On February 8th this year, 20-year-old student Shubamso Pul (left) took his life in his room at the University of Sussex.

Last week his inquest was held in Brighton, where the court was told that Shubamso had attended a walk-in clinic in December last year where he discussed his mental health and was referred to a doctor.

He visited a GP and was prescribed antidepressant medication, with his dose being raised after four weeks when he described his symptoms as having worsened.

Concluding that Shubamso took his own life, coroner Veronica Hamilton-Deeley (right) praised the processes in place to support students, but said that lessons could still be learned from Shubamso’s death. She suggested that his flatmates start a support group, so that if “something like this happens again” then they could speak with those affected and help them through the experience.

She did not suggest that when a patient feels worse rather than better after being prescribed antidepressants, increasing the dosage is not necessarily the best course of action.


September 24 2020

On December 20th 2018, 37-year-old PE teacher Leanne Carroll (left) took her life at her home in Middleton, Greater Manchester. This week, her inquest in Rochdale heard that Leanne had suffered severe bouts of insomnia after calling off a wedding earlier in the year.

Her father Bernard told the inquest in a statement: “Her sister Gemma got a message from Leanne saying she wasn’t feeling right. She said she had not been to work for a week and had not been sleeping properly for weeks. She felt really anxious and wasn’t sleeping and had eczema on her eyes. Leanne had asked for counselling but every time she visited her GP she was prescribed a different medication.

“I had received a text message that said: ‘Dad I don’t feel in a good way please I think I need to go to the hospital, felt suicidal for weeks and worried I am going to do something to myself. I don’t know what to do I feel like I’m going mad.’

It’s the first time she’s ever mentioned harming herself. She had a flashback about feeling that she didn’t want to be here. I tried to contact Leanne when I received the text but she wouldn’t answer. She did answer the phone to Gemma and was hysterically crying. She said she had driven her car on the M66 that afternoon with the view of crashing it but couldn’t go through with it and got home.

She told me she had not been sleeping for some time and everything was getting on top of her. She said she needed to go to North Manchester General Hospital and she seemed relieved that everything was going to get sorted.

She was told she had met the criteria of a voluntary section hospital ward but it was full of drunks and drug addicts and was not the best place for her. Leanne seemed quite accepting of this but admitted she was scared of being on her own. The crisis team visited her and she was told somebody would be in contact regarding medication – however nobody rang.”

Recording a conclusion of suicide due to carbon monoxide poisoning, Coroner Michael Salt said: ‘Leanne possibly didn’t tell those seeking to help her about everything concerning her circumstances. More information could have been obtained from the family in relation to what Leanne was thinking and actually doing. It may not have altered the course of treatment that was provided but, I take the families point on board in relation to that. However I don’t think I can stretch that to say it contributed to her death.”

The coroner failed to inform Leanne’s family that frequent changes in prescriptions of psychotropic drugs can induce suicidal ideation and akathisia, which can lead to acts of self-harm.


September 18 2020

Last week, three teenagers found 17-year-old Matthew Young (right) hanging in a wooded area near his home in Bury, after he had been reported as missing.

Yesterday in Rochdale his inquest was formally opened. The court was told that Matthew “was known to mental health services and took medication for depression.”

The inquest was adjourned, with a full hearing set to take place at a later date.


September 10 2020

On December 28th last year, 32-year-old twins Billy and Joey Smith (left) were found hanging from adjacent trees in a wood near Sevenoaks, Kent. Their deaths were reported widely in the tabloid press, as the twins, who worked as tree surgeons, had previously featured in the TV documentary series Big Fat Gypsy Weddings.

Yesterday’s inquest heard from Billy’s GP, who said that Billy had been prescribed Citalopram and Mirtazapine to deal with his anxiety and depression from December 2017. For the last few months of his life, Billy had been living with his grandmother and had used her Tramadol to treat lower back pain.

Joey, who had been diagnosed with bladder cancer in 2018, and whose marriage had recently ended, “also suffered from mental health issues.” However, no details of his medication were published.

Coroner Alan Blunsdon (right), who recorded a conclusion of suicide, said: “The protective factor for each of these twins was each other, stopping the other from harming themselves even though they both had suicidal thoughts. It is a tragic and sad story of these young men coming to the decision that there was nothing left to live for.”


September 04 2020

On February 29th this year, 27-year-old Tanya Halls was found dead at her home in Lowestoft.

Her inquest, held two days ago in Ipswich at Suffolk Coroner’s Court (left), heard had that Tanya had  been diagnosed with “a mixed anxiety-depressive disorder” in 2016. After working with recovery network Turning Point, Tanya self-discharged in March 2017 saying she felt “quite strong.”

Tanya’s step-father said: “In the lead up to her suicide we had no reason to suspect she would take her own life. She had not been depressed or shown any of the traits…the Thursday before this happened she started a new job as a care assistant and was very positive about this.”

Senior coroner Nigel Parsley (right) concluded: “All of us in life have ups and downs and struggle sometimes. It’s part of being human. But Tanya’s last reported issue was four years before her death.

Although she was on low-mood medication, that is not uncommon and there isn’t anything obvious in the last four years that would give me a clue as to what triggered her to do what she did that night.

She had a three-year period where she struggled but seems to have passed that and seemed to be more stable. I will often see cases where there is a clear trigger point, but the really hard thing in Tanya’s case is there isn’t one.

No one raised any concerns and I think even with the benefit of hindsight we can’t identify why she did what she did.”

The coroner failed to mention that “low-mood medication” can induce akathisia, which may then lead to an unforeseen, impulsive act of self-harm.


August 19 2020

Yesterday’s Greek City Times reported that a British tourist had fallen to his death the previous night from a third-floor hotel balcony in Corfu in a suspected suicide while on holiday with his fiancée. The brief report was also published in the Daily Mail and The Sun.

The unnamed 46-year-old man died just after midnight in the Kanoni region on the south of the island where the couple had been staying for a few days.

Ioannis Aivatidis, Corfu’s medical examiner, told a local news agency: “The side effects of the antidepressants that the 46-year-old was taking will also be examined.”

The man’s fiancée told officials that her partner had been taking medication for a psychological issue.


July 30 2020

On June 20th this year, 37-year-old Adam Slater (right) was found hanged at his home in Clitheroe, Lancashire.

This week’s inquest heard that Adam had been a frequent visitor to a local gymnasium, where he used exercises to regulate his mood. However, because of coronavirus regulations, the gym was closed in March.

Coroner James Newman (left) told the inquest: “In a statement from Alan Slater, Adam’s dad, he said Adam was a very happy, hard-working and genuine man, and they had a close relationship. He said his son had a great social circle and was hardly at home. Mr Slater went on to say that Adam had a few issues with an ex-partner and with the breakdown of a recent relationship and had been to see his GP in March.”

The inquest heard that Adam was then prescribed with antidepressants. However, when this did not appear to be effective, in May, his GP suggested he try taking an alternative antidepressant.

On June 1st, when Adam complained about experiencing side effects while taking the second antidepressant, his medication was then switched back to a higher dose of the original antidepressant.

The prescribers’ official handbook, the British National Formulary, contains the paragraph: “The use of antidepressants has been linked with suicidal thoughts and behaviour. 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.”

However, the coroner chose not to mention the reckless actions of Adam’s GP when he concluded: “Adam had left several notes for his family and friends, all of which indicated his desperation and the desire to end his life. Therefore I return a conclusion of suicide.”


July 27 2020

A report in Saturday’s Mirror revealed that in England, during the past five years, more than 1500 children under five years old were prescribed antidepressants. Altogether, antidepressants were given to 703 one-year-olds, 188 two-year-olds, 285 three-year-olds and 381 four-year-olds..

For children over the age of five during this period, 718 five-year-olds were given antidepressants, while the figures soared to over 6000 prescriptions each year for 11-year-olds and 91000 each year for those aged 16.

The report pointed out that NHS guidance says that antidepressants are not recommended for under-18s as “they can trigger thoughts of suicide and self-harm in this age group. There are also fears that the medication can affect brain development.”

This did not appear to trouble Dr Louise Theodosiou (right), from the Royal College of Psychiatrists, who said that antidepressants can be prescribed for a range of conditions. She said: “The number of children and young people with anxiety and depression is increasing. We want them to get the support they need.”

An article in the British Medical Journal in October 2017 stated that Dr Theodosiou was trying to change attitudes to mental ill health and psychiatry through her role as a spokesperson on child and adolescent mental health for the Royal College of Psychiatrists. She stated: “There are still some families who struggle to understand depression as an illness. Some people worry about over-medicalisation, but the decisions I make when I start young people on drugs are collaborative decisions.”


July 08 2020

On February 26th this year, 17-year-old student Ellis Battersby (left) was reported missing from his home in Marlow Bottom, in Buckinghamshire. Tragically, he was found hanged the following day in nearby woods.

Today’s inquest heard that Ellis had been diagnosed with autism and “fluctuating anxiety”. He was being treated by the Child and Adolescent Mental Health Services (CAMHS).

At Ellis’s last review with a consultant at CAMHS five months before his death, he was reported to be doing well, although he appeared to be anxious about a change in routine brought about by starting at Henley College. His consultant felt that this anxiety would subside as he got used to his new routine.

A toxicology report found that here was neither alcohol nor drugs in his system, apart from therapeutic levels of prescribed Sertraline.

Concluding that Ellis’s death was suicide, coroner Crispin Butler (right) said: “He died in the context of ASD and fluctuating anxiety and previous suicidal thoughts over a number of years.” Perhaps his summation would have been more accurate if he had mentioned the context of Ellis having been prescribed Sertraline, an SSRI drug deemed unsuitable for children because of its propensity to induce suicidal ideation.


July 01 2020

On November 9th last year, Jasper de Pelet (left), an 18-year-old student, lost his life when he drove his car into the path of an HGV lorry on the A303 in Wiltshire.

His inquest at Salisbury Coroner’s Court this week heard Jasper described as “gifted and creative writer.”

A spokesman for his former school said: “Jasper was a uniquely talented individual. He was possessed of tremendous academic ability and had a wide range of passions and interests. Above all, he was an exceptionally kind and gentle young man.”

Jasper suffered from periods of anxiety, especially around exam times. After his death, a journal was found in which he had written: “Even when I am at my happiest, sadness can crush me at any time.”

Although he had been disappointed by his A-level results, he had nevertheless secured a place at Cardiff University. However, he had decided to take a gap year before taking up the place.

Jasper’s GP, Dr Joanna Briffa, told the court that he had “high standards and expectations of himself.” She added that Jasper had been seeing a counsellor, and had been prescribed Fluoxetine shortly before his death.

Coroner David Ridley (right) did not link the prescription to Jasper’s impulsive actions when he concluded: “I have seen the journals, read a few extracts and I noted the evidence from his mum that he had experienced a downturn in his mental health.” He delivered a verdict of suicide.


June 18 2020

Today’s Daily Mail reported the death of 63-year-old Adam Fitzpatrick (left), described by the newspaper as “a leading heart doctor.” He was found hanged near his family home in Wilmslow, Cheshire on January 19th this year.

Dr Fitzpatrick was the medical director of the Arrhythmia Alliance Group, which researches heart conditions.

He had worked at Westminster Hospital in London and also San Francisco and helped to write 16 scientific publications about cardiology. He took up a consultant post at Manchester Royal Infirmary Heart Centre and developed its cardiac electrophysiology service and was said to be ‘highly regarded‘ by his colleagues and ‘adored‘ by patients.

His inquest this week heard from his widow that: “He suffered with mental health problems since his early 20s when he first sought psychiatric support. He was admitted to hospital for it about 21 years ago, then about 10 years ago and then again for five weeks in March 2019 following an episode of self-harm with knives upon his chest.

He suffered low mood and suicidal thoughts on and off for many years. He took an overdose and was treated in summer 2018 and visited the Humber Bridge in February 2019 twice before self-harming with knives twice in that year. Leading up to his death he was in rehab and his mood was up and down and he lengthened his stay three by three weeks…However in January he discharged himself.”

A registered psychiatric nurse at Cheshire and Wirral NHS trust who treated Dr Fitzpatrick in August 2019 told the inquest: “He said he felt mentally well at the time of his assessment and attributed some of his behaviour to therapy he had been receiving privately. He was hoping for a change in his antidepressants and, in addition, referrals were made to the complex therapy team.”

Coroner Heath Westerman recorded a conclusion of suicide.


June 17 2020

On Sunday, the 34-year-old Indian actor Sushant Singh Rajput (right) was found hanged at his home in Mumbai.

Mumbai police issued a statement that the actor was reportedly suffering from depression, as they found medical papers and antidepressants in his house.

According to his close friend Mahesh Shetty, Sushant had stopped taking his antidepressants for the last few days of his life. Just before his death, Sushant told him that he didn’t need the medicine any longer and there was nothing to worry about.

Sushant was best-known for playing the title role in the film M.S. Dhoni: The Untold Story (left), a biography of the celebrated Indian Cricket captain Mahendra Singh Dhoni.


June 06 2020

It was reported yesterday that Adrian Marsden (right), the child psychiatrist who was responsible for the “bad treatment” of 15-year-old Becky Romero at Pebble Lodge Residential Unit in 2017, pleaded guilty at Poole Magistrates’ Court to charges of making indecent photos and possessing prohibited images of children. Police officers had found more than 2000 illicit images of children on his computer, including pornographic pictures of children as young as 8 years old.

Although he had been downloading the images since 2010, Dr Marsden cited the death and subsequent inquest of Becky (left) in 2017 as mitigation. His lawyer said: “He deleted some of the images as he knew what he was doing was wrong, but like a smoker who is trying to quit smoking who keeps some cigarettes he kept some. These, he looked at in times of trauma, such as when he was suffering depression in late 2017 and 2018 after being criticised at an inquest of a young person who took her own life.”

Dr Marsden was suspended by the General Medical Council and has since retired. He avoided a prison sentence but was fined £2500 and given a five year Sexual Harm Prevention Order.

After discovering that Dr Marsden had used Becky’s inquest as mitigation for his actions, her mother Nicky (right) told a Bristol journalist: “How dare he use my child’s inquest as an excuse to use child porn? Everybody gets stressed at some stage in their life and everyone manages to deal with it without resulting to that. I said he was a liar before and he has proved it again. He again has managed to get away scot free.

He’s a despicable man, he disgusts me. As a family, we are again devastated by this man’s actions. He worked in an adolescent unit where he took children into a little room to talk one-to-one with them. Yet he was behaving like this the whole time? I am gobsmacked.

I have been through so much stress because of what happened but I dealt with it. Most people who are stressed go for a walk or have a drink, they don’t turn to that. I wish he had gone to jail and am disgusted that he hasn’t,” she added.


April 09 2020

Because of social isolation legislation, it has been necessary to postpone a significant proportion of inquests that are due to be held. Moreover, many of those that have proceeded have not been reported in the media due to the lack of an available journalist.

However, an inquest held in Winchester via video link was reported in the Basingstoke Gazette today. It concerned ambulance worker Catherine Thomson (27) who was found by her partner, Daniel Langridge, in the hallway of their first floor flat in Hook, Hampshire, on Sunday, November 22, 2019. Daniel told the coroner: “I had no idea that she was going to do this. We were planning on getting married in 2022 and I was unaware that anything was wrong.”

Previously, Catherine had been traumatised at work by a baby who died after a cardiac arrest. In March, she went to see her GP, who told the coroner that Catherine had been feeling low but that she “denied thoughts of self-harm and saw that she was getting help from work.”

Delivering a verdict of suicide, coroner Jason Pegg (left) said: “Catherine was a commendable young lady who enjoyed a relationship with her partner Daniel. She had much to live for, supportive parents and a good job.

“In March 2019, Catherine presented to the GP with low moods for several months and embarked on a course of medication and therapy to address her mental health issues she was suffering from…

“Catherine intended to take her own life by hanging herself. It is tragic that she had demons living in her.”

Instead of investigating the rôle that drugs with verified links to suicidal ideation may have had on Catherine’s state of mind, the coroner chose to opt for a verdict that would not have been out of place in the Middle Ages.


March 14 2020

On the morning of October 3rd last year, 24-year-old Lewis Isaac (right) was found hanged at his home in Cardiff.

At the time of his death, Lewis was studying natural history at Cardiff University. He was a talented rugby player who, as a schoolboy, had been selected for the Cardiff Blues youth team.

Since the age of 16, Lewis had shown an interest in joining the army. The day before he died, Lewis attended an induction day at the Maindy Barracks. Later that day, he told his mother Martine that he was worried he would not be able to join the army because of his mental health history.

Lewis always felt his mental health would not allow him to join,” Martine said in a statement which was read at his inquest last week by coroner David Regan (left). “Lewis had a happy childhood, he was diagnosed with Asperger’s when he was six. He had a massive heart, he found it impossible to leave anyone, he was so caring.”

Martine explained that Lewis had battled with his health for a number of years, and was admitted to Llandough Hospital in February 2019 where he was an inpatient for six weeks following a diagnosis of acute psychosis.

When Lewis was discharged from the hospital in March, he continued to receive weekly care in the form of cognitive behaviour therapy from the intervention psychosis team, as well as taking anti-psychotic drugs and antidepressants.

Speaking at the inquest in Pontypridd, consultant psychologist Dr Somashekara Shivashankar explained that Lewis was very ill during his hospital admission in March 2019, which had a “flavour of a schizophrenia episode“, but he was never formally diagnosed with the condition. On meeting Lewis following his discharge in June, Dr Shivashankar said it was clear that Lewis’s health had improved and he was pleased with the progress he was making.

Dr Shivashankar was the last contact Lewis had with a member of his mental health team on September 26. He told the hearing: “On that day Lewis was positive, he did say he sometimes has low motivation, but there was no evidence of any psychotic symptoms. He said he was getting up around 8am to 9am, he had started back at university, he was taking an interest in rugby again, going to the gym four times a week; he was quite positive. He expressed to have a desire that he wanted to join the officer core at the university. It came across to me that he was looking forward in life.”

Dr Shivashankar advised Lewis that his mental health would not be an issue for his joining the army but told him he had to get better first. There was also a discussion over Lewis reducing his medication dosage. He added that, while Lewis presented signs of depression such as low motivation, he was not clinically depressed and there was no immediate concern for his life.

Reviewing the evidence, Mr Regan delivered a narrative conclusion, saying that he could not confidently say that Lewis intended to take his own life.

Speaking after the inquest, Lewis’s mother said: “He was a lovely kid, he was very kind and caring, he always worried about everybody else.” Martine expressed concern over the increasing numbers of men to lose their lives in this way, adding that she would like to set something up to help others in Lewis’s memory. She added: “I just want to know when it is going to stop.”


March 10 2020

On October 22nd last year, 23-year-old Tom Hollands (right) fell to his death from a cliff in Brighton. Tom, who worked as a laboratory technician at a cosmetics company, was described as a “passionate” musician.

His inquest last week heard that, in 2018, Tom had reported feelings of anxiety and obsessional thoughts to his GP. The court heard that he was given a “working diagnosis” of obsessive compulsive disorder (OCD) which had not been officially confirmed. Although he was not diagnosed with depression, he was prescribed Fluoxetine.

Tom’s father told the inquest: “For most of 2019 he felt he was getting better and we were all very happy. We thought the OCD was intrusive but we did not realise the risk of it getting this serious. It came as a shock to everyone.”

Tom had wanted to reduce his medication and temporarily stopped taking Fluoxetine in September 2019.

Coroner Veronica Hamilton-Deeley (left) said: “Within a month of stopping it he reported a steep decline and suicidal thoughts to his GP, who said he must start taking the Fluoxetine again, as there was clearly a connection.”

The coroner recorded a conclusion of suicide and Tom’s cause of death was given as multiple injuries due to a fall from height, with obsessional thoughts and anxiety as additional causes.


February 24 2020

On September 4th last year, 16-year-old Cameron Warwick (right) was found hanged in woods near his home in Fareham, Hampshire.

His inquest last week heard that Cameron , who was a talented artist, had been diagnosed with autism and depression. When he was 12, Cameron had come out as gay which, his mother said, had led to his being bullied relentlessly at school. Some of the pupils threw food at him during lunch breaks, tripped him up in the corridors and called him names – leading her son to self-harm as he struggled to cope.

Paying tribute to their beloved son, Cameron’s parents said in a statement: “Cameron was a much-loved, gentle and kind young man. His illnesses made it impossible for him to continue to live in a world which he did not understand, and one which made little effort to understand him. We miss him with all of our hearts, and would urge others to be compassionate to other people’s vulnerabilities, or to share their own and seek help to avoid other such tragedies.”

Coroner Jason Pegg (left) recorded a verdict of suicide, concluding: “Cameron had this background of autism – which resulted in bullying at times. Not only did he take his own life, he intended to do so.”

There was no mention of medication that may have been prescribed for Cameron’s autism and/or depression in any of the newspapers that covered the inquest.


February 22 2020

This morning, The Argus, a newspaper serving the Brighton area, reported on yesterday’s inquest of Lauruell Clarke (right), a high-achieving 14-year-old schoolboy from Hove. On October 11th last year, Lauruell was found hanged at home.

The inquest heard that Lauruell had been referred to East Sussex Child and Adolescent Mental Health Services (CAMHS) after he took an overdose of paracetamol in March last year. It was agreed at CAMHS that Lauruell should have counselling through his school’s health and wellbeing service, but the referral was never made by CAMHS. The court heard that Lauruell’s father had called CAMHS on October 10th, the day before Lauruell was found dead, to say he was worried about his son and to ask why no counselling had been arranged.

Coroner Veronica Hamilton-Deeley (left) recorded a conclusion of suicide and said: “I believe this was a spontaneous decision. Lauruell was a high achiever and he was loved and admired. There are so many pressures on young people these days, I’m never quite sure how they cope.”

On Tuesday, The Star, a Sheffield-based newspaper, reported on the previous day’s inquest of 17-year-old Joshua Gordon-Smith (right), described as “talented and intelligent”, who had been found in his bedroom in June 2019.

Joshua’s mother told the inquest that Joshua had been upset about a family friend who had died from suicide, and had also been traumatised after finding her suffering a medical problem at their home for which he blamed himself. Joshua’s parents had also been involved in a custody dispute.

The inquest was told that the family had been helped and supported by Sheffield City Council’s Multi Agency Support Team (MAST) which offers preventative intervention over a range of issues of social care, as well as the local Child and Adolescent Mental Health Services (CAMHS).

Joshua’s mother had raised questions about whether opportunities were missed with the level of support, as Joshua’s case had been closed by the agencies before Joshua’s death.

Recording a conclusion of suicide, coroner Abigail Combes said: “I can see that he and you have had a lot of intervention from various people who it seems were trying to do their best by Joshua and by the family in difficult circumstances. Whilst I can see that some concerns have been raised by both of you as to whether there were failings in Joshua getting the support he should have had I can’t find anywhere that would have made a difference to the outcome for Joshua. I think Joshua was a teenager. He was going through teenage angst and he was trying to support everyone around him as well and did so incredibly well until he couldn’t do that any longer.”

Any medication that may have been prescribed to either of these talented, intelligent and high-achieving boys was not mentioned in either report.


February 21 2020

On October 15th last year, 58-year-old Heather French (left) was found hanged at her home in Portslade, Sussex.

Her inquest in Brighton this week heard that Heather, a trained psychotherapist, had suffered with depression and had been diagnosed with bipolar disorder late in life. She was prescribed antidepressants and an anti-psychotic drug.

Initially, she seemed to be making a good recovery but she chose to stop taking one of her medications for a period and her mental health deteriorated last summer following a relationship break-up.

Daniel Young, a community psychiatric nurse with the Brighton and Hove Assessment and Treatment Service, supported Heather and had referred her to the mental health crisis team in September but they found that she did not meet their criteria for treatment at that time.

At their meeting five days before her death, Heather told Mr Young that she had taken an overdose three days earlier which had made her sick.

He told the court: “She had restarted taking the Venlafaxine anti-depressant tablets and had said they were making her dizzy, but she had taken these drugs in the past without any problems. Another referral to the crisis team could have been made at that point, but it would have been against Heather’s wishes as she saw it as another step towards a further admission to hospital.”

The court heard that Heather’s family were not informed about her overdose, which occurred a week before her death.

Coroner Catharine Palmer (right) delivered a verdict of suicide and commented: “We cannot see whether things would have been any different. Heather was extremely fearful of hospitals and it could have pushed her over the edge.” She did not mention the suicidal ideation which may well have been triggered by her adverse reaction to her prescribed drugs.

In a statement, Heather’s family said: “Heather was a bright, creative and loving woman. We are saddened that her denial of her mood seems to have been taken at face value and does not seem to have been fully explored with her or sufficiently communicated between the relevant mental health teams, or to her family during the last week of her life.”


February 16 2020

On May 27th2017, 15-year-old schoolboy James Garrard (left) was found hanged in woodland, close to his school in Frimley, Surrey.

Last Tuesday, SurreyLive reported that, on the previous day, his inquest began at Woking Coroner’s Court. On the first day the court was told that, until October 2016, there had been no signs that James was upset. He was then “diagnosed with mixed anxiety and depression”; a bereavement in his family earlier that year was cited as one potential contributing factor.

On the first day of the inquest, the student support officer at James’s school criticised the lack of support the school received from CAMHS and also from HOPE, a multi-agency service for young people. She said that, although the school recognised that James needed extra support: “It was a fight to have him signed off. It made us look like we were trying to get rid of him, but we just wanted him to get the proper help.”

There were no further reports published until after the conclusion of the inquest four days later, when Surrey Live reported that: “Throughout the week-long inquest, witnesses were questioned as to the support James had received.”

Coroner Anna Crawford found that the care administered to James by the Trust was appropriate, adding that she had heard evidence throughout the inquest to say that changes had since been made to the provision of child mental health services.

She delivered a narrative verdict, telling the court: “It is unclear if he did it with the intention of taking his own life or if it was a cry for help with the hope of being found in time.”

After the inquest, a statement released by those representing his family said that they felt “that the extent and nature of James’s difficulties and the pressure on them was not adequately acknowledged by mental health services“.

If details of medication prescribed to James were discussed during the five-day inquest, they were not mentioned by SurreyLive.


February 6 2020

On August 16th 2016, 34-year-old Sarah Harvey (right) lost her life when she jumped from the 54th floor of an apartment block in Dubai.

An inquest, held in Cheshire this week, heard that Sarah had grown up in the Macclesfield area, and had moved to Dubai after completing a law degree at Sheffield University in 2005. She had worked for Emirates Airways, before pursuing a career as an assistant company secretary for a luxury hotel group.

The court was told that Sarah lived in an apartment at the iconic 428 metres high Torch building (left) in Dubai Marina. Before her death, she had been battling depression and anxiety and had been prescribed antidepressants.

In a statement, Sarah’s parents said: “Her general health in the final months appeared excellent. There were visits to the UK and phone calls but they revealed nothing and she acted very well. Sarah discussed with us that she was being prescribed antidepressants but she didn’t elaborate to the depth of her despair. Her friends had noticed a change in her normal going out appearance in the final weeks and they recommended that she sought help which she did do.”

Dr Fawzi Benomran (right), head of the Dubai police department of forensic science and criminology, told the inquest: “Her friend reported that the deceased had suffered from depression and was taking medication for it. I sent a sample of blood to be analysed and it indicated a low concentration of antidepressants. But there was no alcohol or narcotic substances.”

Recording a conclusion of suicide caused by her fall, coroner Heath Westerman said: “This is a tragic loss of somebody who had a great deal to live for and worked very hard to get where she was.” He ignored any possibility that Sarah’s death may have been linked to antidepressant-induced akathisia.


February 2 2020

On July 7th 2018, 36-year-old Amanda Harris (left) was stabbed to death in front of their three children by her partner, who then set fire to their house in Melbourne before driving off with the traumatised children. Neighbours found Amanda and dragged her body from the fire.

At his trial last week, 40-year-old Daniel Eckersley (right) admitted murdering his wife while in the midst of a psychotic episode, and was sentenced to 18 years in prison.

The court heard that Daniel’s mental state had deteriorated markedly in the period before the homicide.

Days before she was killed, Amanda took Daniel to the doctor. He was described as “depressed, sad and tearful” and was convinced that Amanda was trying to poison him and the children. She was so concerned that she also contacted his family.

After his arrest, it was discovered that Daniel had taken more than the recommended amount of the painkiller Tramadol and also the antidepressant Pristiq. In the UK, this drug is better known as Desvenlafaxine, a variation of Pfizer’s SNRI drug Venlafaxine.

The judge described the killing as an act of “savagery” committed against a defenceless woman, but handed Daniel a reduced sentence because he was suffering from psychosis. He told Daniel: “It must be clearly acknowledged that when you committed this horrible and intensely violent crime, you were in a severe acute psychotic state.”

The judge also announced his intention to ask Victoria’s coroner to look at whether doctors should be given more information about the risks involved.


January 6 2020

On October 14th 2019, 17-year-old A-level student Rachel Collins (right), described as “intelligent, witty and articulate”, died when she fell from a bridge near her school in Haslingden, Lancashire.

At today’s inquest, Rachel’s father Sean spoke of his concerns that she had been left without her prescribed antidepressants for six weeks after a mental health assessment in August. There had been a mix-up and Rachel had not realised that she should have gone to her GP to collect the prescription herself until it was sorted out at an appointment on October 9th, just five days before her death.

Sean said he did not feel that it was right for the emphasis to be placed on a vulnerable teenager, adding: “We just want to make sure this does not happen to any other young girl.”

Coroner Richard Taylor (left) said that he was satisfied that lessons could be learned from Rachel’s death, including issues surrounding medications. Returning a suicide verdict, the coroner said her death could not have been predicted and added: “There did not seem to be any difference in her that day. It was likely a decision made that day when she could not cope and became overwhelmed.”


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News File: 2018

News File: 2019