Blogging Since 2006

Blogging Since 2006
WHEN INJUSTICE BECOMES LAW, RESISTANCE BECOMES DUTY

Monday, March 18, 2013

Are Coroners Ignorant of Facts?

I think that I am familiar with the fact that you are going to ignore this particular problem until it swims up and BITES YOU ON THE ASS! 



Are coroners ignorant of facts?

It's a fair enough question and one that I'd answer with a resounding 'yes'.

I can't imagine for one minute that choosing to be a coroner is a pleasant experience. I'm reminded of when I was a kid and asked what I wanted to be when I grew up - footballer, truck driver. Perversely  some might suggest, I even had being a postman marked down as a goal. I cannot recall one single kid either in my class at school or social friends ever wanting to be a coroner - to be honest I don't think anyone knew back then what a coroner was. Who wants to work with dead people anyway?


It takes a special breed of person to become a coroner. Day in, day out, they sit and listen to evidence of how Joe Bloggs was cut from the wreckage of his car or how Jane Doe was brutally gang raped then murdered. All this after eating breakfast, a spot of lunch then home for dinner/tea with their partners and families.

Yes, it takes a very special kind of person to be able to switch off emotions, images, grief.

It has to be said, coroners are exceptional in switching off, they have this in-built mechanism that comes into play - it enables them all to step out the bubble of overwhelming loss - they [think] they know they may be able to shed some light on how and why a person died but they can only do so by 'switching off'.

It's plainly obvious to a growing number of people that coroners not only switch off emotion they also switch off the logic button. One would have thought that coroners, of all people, could apply simple logic to sometimes complex inquests. They choose not to. Having switched off the emotional attachment they also switch off the human attachment. They become God.

Many readers will know that I've recently promoted the website, AntiDepAware. Brian, the author and researcher, has collated over 1600 inquests where the use of antidepressant type medications were involved. One of Brian's latest posts really struck a chord with me - it pretty much sums up what I am trying to say in this post.

Brian has carefully followed the inquests of particular coroners, in his post, Coroner’s Progress 2, he highlights clearly that certain coroners are either playing the God card or, as I suspect, are just pig-headed and ignorant about a problem that is so glaring even a kindergarten pupil could spot it.

"Norfolk Coroner William Armstrong", writes Brian, "is retiring at the end of September 2013."

Brian goes on to write how Armstrong became influential in changing the procedure for licensing shotguns. Apparently Armstrong had been involved in many inquests where firearms were concerned so he decided to do something about it. Kudos to Armstrong for that.

However, where Armstrong saw a link between suicide and firearms he has, on many occasions failed to see the link between suicide and medication. He's not alone, almost every single coroner fail to recognise this common link.

Here's part of Armstrong's career highlights as a coroner, courtesy of AntiDepAware.


Joanne Brown, 41 [1]

… Since about 2005 she had been suffering from serious mood swings resulting from a mental health condition for which she was receiving treatment, although her medication was not always being managed effectively …

….. The coroner said Mrs Brown had suffered for several years from a mental disorder causing mood swings and one happened on December 13. She clearly intended to bring her life to an end and he recorded a verdict of “suicide while suffering from a mental disorder”.



Mark Osler, 51 [2]

Mr Osler shot and seriously injured his ex-lover, then shot himself dead.

… Greater Norfolk Coroner William Armstrong read a statement by Mr Osler’s GP saying he was being prescribed anti-depressants.

He had mentioned having fleeting suicidal thoughts in June. On July 9, he said he was still feeling low and anxious and sleeping badly but never expressed any intention to hurt anyone or take his own life … What happened was completely unexpected and a great shock …

No further comment by Mr Armstrong on antidepressants was reported. 


Pamela Thomas, 59 [3]

A CORONER is asking Norfolk police to consider reviewing the scope of firearms licence applications after a woman died from shooting herself, an inquest heard …

… He said there was “no deficiency” in the procedure when Mr Thomas received his latest firearms licence.

But he added: “I have noted that when someone applies for a gun certificate the police will ask questions of their character. There is no obligation to ask about the physical or mental health of everyone in the household.”

Mr Armstrong said at the time the licence was granted Mrs Thomas had not made an attempt to take her own life, but she had been suffering from depression for a long time.

“For a woman to kill herself with a gun is a very rare event,” he said.

The coroner told the hearing this was one of three shotgun suicides in a short period of time and he proposed to ask the chief constable in Norfolk to look at how firearm licences are issued.

However, no comment from Mr Armstrong was reported on the following:

… A medical report from her GP, Adrian Clifton, said she had made good progress on her increased anti-depressants, following her attempted overdose in March which she “regretted” …



These are just three examples of Armstrong's ten reported inquests that AntiDepAware offer for scrutiny. On no occasion has Armstrong ever felt the need to investigate the antidepressant/suicide link - Why?

The three inquests [above] highlight the use of firearms in three separate deaths. They also highlight how all three deaths had another link - antidepressant use.

Armstrong chose to ignore the antidepressant link in a further 7 inquests he conducted, 6 of which involved no firearms.

I find it astonishing that a coroner could turn a blind eyes to overwhelming evidence that, at the very least, warranted further investigation.

Was Armstrong switched off during these inquests, so much so that he missed the link or did he just choose to ignore the link because, hey, depressed people have "mental disorders", right?

We see many Armstrong type figures do the same on a daily basis throughout global coroners courts. They sit in judgement of the dead when in actual fact they should be sitting in judgement for the dead.

Five years ago the 3 month long inquest of 17 year old Toran Henry came to it's conclusion. The coroner stated at the end that children should continue to take their medication as and when prescribed. Toran had killed himself a couple of weeks after being prescribed fluox, the generic version of Prozac. Earlier in the inquest the presiding coroner had stated that in his 8 years of being a coroner, "I struggle to recall a suicide in which Fluoxetine was regarded as being a cause or development."

The pharmaceutical company that manufacture fluox, Mylan Labs, had received an adverse reaction report for Toran. After 5 long years they concluded that the fluox Toran ingested was the most probable cause of his induced suicide. [4]

The inquest of Sara Carlin, an 18 year old from Oakville, Toronto saw Coroner's Counsel, Michael Blain, appear in front of TV camera's on the first day of the inquest. He told reporters and the watching public, "The Courts acknowledge that this medication can increase thoughts of suicide in particular patients but 'they' don't think that the medication played a role in Sara Carlin's death." [5]

This was day one of Sara's inquest. It appears that 'the Courts' had already made their mind up without first hearing the evidence.

Sara hanged herself after being prescribed GlaxoSmithKline's Paxil, known as Seroxat in the UK.

This brings me, conveniently, to a study published in International Journal of Risk & Safety in Medicine [6]

Although the study focuses on violence and not suicide the conclusion pretty much highlights where coroners are either enjoying the role of playing God or ignoring the evidence. The authors conclude:


The deep trench that separates the law from forensic pharmacology is unfortunate and causes injustice, largely invisible to the legal profession. Legal processes generally seem reluctant to implicate the drugs, for whatever reason, preferring instead to look elsewhere. This unexplained bias needs to be examined. Even if people are in general prepared to accept the evidence, many cannot bring it to bear in specific cases.
Two steps could be taken now. First, legal administrations in all countries should ensure that courts under their control obtain appropriate expert evidence from a forensic psychiatrist or pharmacologist in all cases where a prescribed drug could have caused violent or other criminal behaviour.
Second, criminal courts and coroner’s courts should be supplied with an annotated list of drugs that can cause violent behaviour. That need not take long because solid building blocks for such a list have recently been compiled from national pharmacovigilance databases in the United States and in France. The list should be updated regularly.

I cannot for the life of me apply any logic to the stance of coroners regarding antidepressants and suicide. I'm constantly reminded of the line from the movie Jaws.


Mayor Vaughn: I don't think either of one you are familiar with our problems. 
Hooper: I think that I am familiar with the fact that you are going to ignore this particular problem until it swims up and BITES YOU ON THE ASS! 

It takes a special breed of person to become a coroner...

Bob Fiddaman





[1] Tragedy of mum's shotgun suicide - Published on 28/03/2010 - Lynn News
[2] Gunman took his own life, inquest rules - Published on 28/06/2011 - Lynn News
[3] Coroner’s appeal after Heacham gun death - Published on 19/07/2011 - Lynn News
[4] Mylan Pharmaceuticals Admits their Drug is the Probable Cause of My Son’s Suicide - Published on December 16, 2012 - Mad In America
[5] Sara Carlin Inquest: Day One [VIDEO]
[6] Case histories as evidence - International Journal of Risk & Safety in Medicine - Andrew Herxheimer, David Healy and David B. Menkes 24 (2012) 23–29





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