Tuesday, March 05, 2013

Sometimes Coroners Get It Wrong...

Toran Henry

Today marks the 5 year anniversary where 17 year old Takapuna teen, Toran Henry, was prescribed the antidepressant, Fluox. For those that don't know, Fluox, is the generic name of Prozac and is sold and marketed by Mylan NZ.

Toran, under the influence of Mylan's drug, killed himself just two weeks after starting it.

Mad kid, must have been mentally ill, he was distraught because of the circumstances in his life, have all been used as excuses.

In fact during the 18 day inquest it was even suggested by those who were supposed to be caring and looking out for him that Toran's mom, Maria Bradshaw, was a poor mother who used to starve her son. Everything but the truth.

After hearing all the evidence Coroner Murray Jaimeson, now retired, criticized the care of Toran by Marinoto Child and Adolescent Mental Health Services as deficient, including their lack of advice on fluoxetine's side effects.

Strangely, he did not make any finding on whether taking the drug contributed to Toran's death. His final recommendation however was that "children should take their medication as prescribed."

That utterance by Jaimeson is a matter of record.

5 years on and we now know that Fluox played a significant role in Toran's death. Mylan have wrote to Toran's mother and, minus an apology, have assessed that fluox was the most likely cause of Toran's suicide. No offer of condolence has ever come from any individual associated with Mylan NZ or the global headquarters of Mylan Pharmaceuticals in America.

One could, if they wanted to, praise the actions of Mylan. It's very rare that a pharmaceutical company admit to manufacturing a product that killed... or most likely killed an individual.

Personally, I find the actions of Mylan somewhat disturbing. On one hand they claim that their product contributed to Toran's death yet on the other hand they offer no apology or condolences. This, to me at least, smacks of a company denying any accountability.

Toran's mother Maria has, after 5 long years, finally received an updated CIOMS report from Mylan NZ. They had previously sent out a report to Maria with wrong information, for instance they stated that Toran was 19 at the time of his death - one has to ask if they initially did this because they didn't wish to flag that fluox was dangerous for the adolescent population.

So, what if Coroner Murray Jaimeson would have had at his disposal this new evidence, an admission from a pharmaceutical company that their product was the most likely cause of a suicide? Would it have meant that the inquest could have been resolved at an earlier time? Although the inquest ran for 18 days it was over a period of 3 months.

Mylan should hold up their hands here. To take 5 years to release 'correct' information regarding an adverse event related to one of their products is abysmal public relations. To sit and watch a mother have to endure aggressive cross-examination by seven teams of lawyers at her son's inquest is also a shameful act by anyone's standards

Mylan must have breathed a huge sigh of relief when Coroner Jaimeson laid no blame on their drug - they knew different but, as most pharmaceutical companies do, they kept quiet.

So, what now?

So, given this new evidence and Murray Jaimeson's previous criticism of Marinoto Child and Adolescent Mental Health Services, what happens now?

In a word, nothing.

Marinoto Child and Adolescent Mental Health Services falls under the Waitemata District Health Board [DHB]. Nobody, not one single person, deemed Toran's suicide important enough to file an adverse event report to CARM [Center for Adverse Reactions Monitoring]. In fact, it appears that this is standard practice for Waitemata.

Between the January 1st 2007 and December 31st 2010 there have been 28 clients who have all carried out suicide whilst under the care of Waitemata DHB. Of these, not one single adverse drug reaction was reported by any employee of Waiemata DHB. [1]

New Zealand is currently listed as the second best country in the world for reporting adverse events for prescription medication. The figures from Waitemata DHB would suggest otherwise, wouldn't they?

Of the 28 suicides under the 'care' of Waitemata DHB, 4 had their diagnosis deferred, of these 4, of which Toran was one, three were prescribed medications such as fluoxetine, citalopram, temazepam, zopiclone and diazepam.

Moreover, of the 28 suicides, there were 6 clients whose diagnosis was never recorded. Quite staggering, nae appalling that 6 patients could have gone through a system where not one person administering drugs actually knew what they were treating.

Of these 6 patients 5 were administered medications.

Four of the suicide victims were children. Of those four, three were medicated but had no diagnosis recorded.

Let's just take a look at some of the cocktails here:

Patient One: citalopram, quetiapine, zopiclone

Patient Two: zopiclone, paroxetine, quetiapine, tramadol, paracetamol

Patient Three: citalopram

Patient Four: buproprion, fluoxetine, nortriptyline, tramadol, paracetamol

Patient Five: triazolam, dothiepin

Once again, Waitemata staff failed to file any adverse reactions to these patients who were given various cocktails of mind altering medications without actually having any diagnosis which staff could assess and work from.

The remaining 16 who were labelled with a diagnosis were all prescribed mind altering drugs.**

**Two clients of Waitemata have been deleted from the following list. One had not been recorded with a diagnosis and was, allegedly prescribed nothing, the other was diagnosed with substance abuse and prescribed nothing.


Patient One: Major depressive disorder - citalopram, risperidone

Patient Two: Obsessive compulsive disorder, anxiety disorder, major depressive disorder - venlafaxine, quetiapine, lorazepam

Patient Three: Polysubstance dependence, depressive disorder - paroxetine


Patient Four: Schizophrenia [paranoid type], PTSD - clonazepam, zopiclone

Patient Five: Mood disorder due to general medical condition - nortriptyline, citalopram

Patient Six: Substance related disorder, alcohol dependence, amnestic disorder due to general medical condition, major depressive disorder - olanzipine, nortriptyline, diazepam, lorazepam

Patient Seven: Major depressive disorder - citalopram, risperidone, zopiclone

Patient Eight: Major depressive disorder, cannabis abuse - olanzapine, citalopram, zopiclone


Patient Nine: Narcissistic personality disorder - clomipramine, venlafaxine, olanzapine, zopiclone

Patient Ten: Bipolar affective disorder - zopiclone, quetiapine, benztropine, flupenthixol

Patient Eleven: Schizophrenia [paranoid type], PTSD - zopiclone, fluoxetine, clozapine, lorazepam

Patient Twelve: Major depressive disorder, alcohol abuse - clonazepam, quetiapine, venlafaxine, diazepam, olanzapine

Patient Thirteen: Schizophrenia [disorganised type] - clozapine, risperidone, lorazepam, amisulpride, olanzapine, zopiclone, aripiprazole

Patient Fourteen: Schizophrenia  [residual type] - risperidone, clozapine


Patient Fifteen: Major depressive disorder - zopiclone, quetiapine, mirtazapine, olanzapine, venlafaxine, lithium

Patient Sixteen: Bipolar affective disorder - lamotrigine, quetiapine, zopiclone

That's really quite a list and quite a cocktail of medications that some were on.

Remember, all of the above completed suicide, not just the last 16 I've mentioned but ALL of the above.

Given that prescription medication, particularly psychiatric medication, can cause some serious adverse events, one has to beg the question that out of every single patient given medication whilst under the care of Waitemata DHB, why were no adverse events reported by staff?

Just what is it they were trying to hide?

If you think the above figures are appalling, you'd be right.

One can see a pattern throughout. Medications have been prescribed to patients when there has been no actual diagnosis of those patients.

Medication has been prescribed to patients when staff at Waitemata had no idea what the diagnosis was.

Medication has been mixed with patients despite strong warnings in literature and on product information that certain medications may cause harm when mixed.

Not one single staff member alerted CARM.

Based on this evidence one would suggest that adverse reactions to psychiatric medication is vastly under reported in New Zealand.

Obviously, we cannot just take one DHB's lackadaisical approach to patient welfare. For that, we'd need a much broader, thorough investigation.

Well, that's underway.

All DHB's have been contacted and asked, under the official information act, for information regarding suicides under mental health care.

The preliminary results show no change in the trend of Waitemata. In fact out of the 12 or so replies I've had so far, not one DHB have reported suicide as an adverse reaction to CARM.

If the death of one teen wasn't enough to shake the system here in New Zealand then what will it take for coroners and mental health advocates to sit up and take notice?

Should it really be left to a grieving mother and her partner to show coroners that they sometimes get it wrong?

Maria Bradshaw, mother of Toran Henry

Maria Bradshaw was forced to sell her family home to pay for lawyer fees throughout the inquest. The bill totalled around $70,000 and came on the heels of paying over $11,000 for a funeral. Not many single mothers have that kind of cash on hand. Had Mylan acted promptly the inquest conclusion would, it's safe to say, have been much different and of much shorter duration and therefore far less costly. Mylan even refused Maria's request to refund the cost of the drug which clearly was a defective product which did not deliver on any of the claims the company made about its effectiveness. The cost of Toran's prescription was $3

Had Mylan acted honestly and ethically, I don't think for one minute that a coroner would claim that "children should take their medication as prescribed"' when  faced with an admittance from a drug manufacturer that their product most likely caused the suicide in the individual.

In respect of Toran, his mom, Maria, telephoned Kaye Brightly earlier today. Brightly had prescribed Toran fluox when he was 16. Toran suffered an adverse reaction to it [violent, and suicidal thoughts and behaviour] so came off it. Almost a year later Toran was prescribed fluox again, this time by a trainee psychiatrist who was supervised by Kaye Brightly.

In her conversation with Brightly this morning, Maria asked her if anyone at Waitemata does anything differently today opposed to five years ago. Brightly told her, "I can't talk about that".

Meantime, the trainee psychiatrist, Zoran Simovik, who prescribed Toran fluox for a second time, has, it appears, disappeared off the face of the planet.

No DHB in New Zealand have any record of Zoran Simovik on their books.

Simovik assessed Toran in a public cafe and, judging by the inquest transcripts [which I've read] may have committed perjury under oath, at least that's my assessment of his sworn evidence.

Those transcripts, in the interest of public safety, will be made available soon. I oppose those sanctions put on Maria Bradshaw by Coroner Jaimeson which prevent her naming those involved in Toran's care, particularly when he got it so wrong with regard to the medication given to 17 year old Toran Henry.

A copy of this is being sent to the CEO of Mylan Pharmaceuticals, Heather Bresch. I've sent her three emails in the past, all of which she has failed to acknowledge.

Bresch, pictured below, is no stranger to controversy. Her MBA degree from West Virginia University has come under much scrutiny. This from the Post Gazette [2]

"West Virginia University has awarded an MBA degree to Heather Bresch, a politically well-connected top executive at drug giant Mylan Inc., rewriting university records that originally showed she had completed only about half the credits needed to earn the degree."

She also has four children.

Mylan CEO Heather Bresch with husband, Jeff

If you or anyone you know has been affected by suicide and you wish to talk about it then please contact Casper, the New Zealand based suicide prevention charity.

Bob Fiddaman

[1] Information collected from Waitemata District Health Board under the Official Information Act.
[2] Mystery in Morgantown - Post Gazette - December 21, 2007 [Link]

Back Stories:

New Zealand Prozac Case File - Toran Henry

New Zealand Prozac Case File - The Loss - Part II of IV

New Zealand Prozac Case File - The Inquest, The Suppression Revealed - Part III of IV

New Zealand Prozac Case File - Mother On A Mission - Part IV of IV

Mylan NZ, a Lawyer, Causality and U-Turn

Mylan Pharmaceuticals: The Emails, U-Turns and Denials

Mylan NZ and the 36 Hours

Mylan's Fluox Can Probably Induce Suicide, admit Mylan