Image: Sara Carlin
SARA CARLIN INQUEST – JURY VERDICT ANALYSIS
by Neil Carlin
I have had many people contact me and ask why the jury would make such sweeping recommendations if they did not find Paxil, in their verdict, to have a causative role in our daughter’s death. Below, is the answer that I have sent to them.
On the cause of death the presiding Coroner – Dr. Bert Lauwers - instructed the jury as follows:
“.. and I direct you to the expert opinion given by Dr John Fernandez which is exhibit number 4. He was the only person called with respect to giving a medical cause of death you recall that. So I would take his report and use his determinations seriously.”
“He gave the cause of death as hanging by ligature and he put in brackets electrical chord while under the influence of cocaine and ethanol and with therapeutic levels or paroxetine”.
The issue here is the use of the adjective “therapeutic” to describe Sara’s post mortem femoral blood concentration of Paxil – which to ordinary people might imply a clinically effective concentration, We argued prior to the jury charge that – the use of the word therapeutic was misleading and was meant by the toxicologist to indicate that Paxil was not at a concentration consistent with death due to fatal overdose of the drug by itself and nothing more – the actual post-mortem concentration considered to be fatal due to overdose is about 4 times higher than Sara’s.
And that it is obvious in this case that the concentration of Paxil (or any drug) did not cause incapacitation preventing her from fashioning a noose and killing herself. Her concentration of Paxil is actually about 2 times higher than the highest (90th percentile) concentrations observed in therapeutic drug monitoring (TDM) studies. ie. she may be a poor metabolizer of the drug – this is something that could have been determined by the OCCO and was not & is something we are following up on.
He ignored our request to properly instruct the jury on this point.
We are not certain why but “therapeutic levels of paroxetine” was left out of the verdict – perhaps the coroner had a change of mind - which in our view was just as well as it was misleading in any case. The jury would never be allowed to list Paxil as a contributing factor as can be seen below may have implied a legal responsibility or liability directed toward GSK.
On the Manner of death he further instructed the jury to find suicide as follows:
“I think we can dispense with the options of, natural, accident, homicide or undetermined. Suicide is a death resulting from the intentional act of a person knowing the probable consequence of what he or she is about to do that is an action that results in his or her death.”
He does not remotely consider the possibility that under the influence of Paxil, ethanol & cocaine – she would not be capable of understanding the true finality of her violent act.
He then instructed the jury not to blame or assign legal responsibility
“It is one of my responsibilities as presiding coroner to inform you of the laws that apply to your duties as jurors in this inquest. If a verdict does not follow the laws it's regarded an improper verdict. A true verdict required on the coroners (..) is one that must include an answer to each of the five questions that you score on your own. It's in your ability to inquire in the death of Sara Carlin and determine of the evidence presented at the scene in question, her identity, how and where and by what means the deceased came to her death and without partiality or biased toward any person and render a true verdict in accordance with this such evidence. In addition to answering the mandatory questions coroner's acts specifies in section three that a jury shall not make any finding in (... ) responsibility or express any conclusion of law on any matter arising out of the inquest. No one can be found guilty and discussions of criminal responsibility, professional negligence or liability do not have any place in the coroners system or your end. You are also prohibited from making any comment or commendation with indication of the findings.”
We simply asked that along with alcohol and cocaine (toxicology consistent with one recreational dose) Paxil - without being described as therapeutic - be named. The jury was not permitted to do this as it may have implied a finding of liability directed to GSK/Paxil.
So unable to find Paxil as a contributing factor in Sara’s suicide, the jury did the best thing they could and clearly implicated the role of Paxil and lack of proper medical care by the breadth & depth of their recommendations – they could simply have returned a verdict with no recommendations. We absolutely got the very best result that this coroner system could possibly give.
Neil Carlin
For back stories on the Sara Carlin inquest download the PDF File HERE
Fid
ORDER THE PAPERBACK
'THE EVIDENCE, HOWEVER, IS CLEAR...THE SEROXAT SCANDAL' By Bob Fiddaman
SIGNED COPIES HERE OR UNSIGNED FROM CHIPMUNKA PUBLISHING
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