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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New Website Challenging Coroners About Suicide

I love it when an idea comes along that has been so blatantly obvious to me... that it's passed me by.

There are many bloggers who have their own styles, their own personal stories to tell, their own take on the pharmaceutical industry, psychiatry, antidepressants.

An area that has interested me has been the whole coronial process. I first became interested in this during my coverage of the Sara Carlin inquest and later the inquests of Shane Clancy and Toran Henry. Three young human beings whose lives were cut short by suicide, all were seemingly normal kids, all were taking antidepressant medication at the time of their deaths, namely, Paxil [Seroxat], Citalopram [Celexa], and Fluox [Prozac].


AntiDepAware is a new website that challenges the coronial system, it's a fascinating read and the author, Brian, has collated many media stories where suicides have occurred but coroners have just ignored the medication link.

Yes, it's another website created to make people aware of antidepressant dangers but where it differs from many is it highlights the failure of coroners to take this issue seriously. It's coming from another angle that I like most about Brian's website, that and the fact that he has meticulously crafted a very strong database of 1600 inquests in England and Wales between 2003 - 2012.

Brian has painstakingly gathered all the information, which he freely admits is just the tip of the iceberg, through various media resources. He writes:

"...all the information here has been found on the Internet, mostly in the archives of local newspapers. I have had no privileged access to any other material. I have limited myself to reports from the past 10 years concerning deaths in England and Wales.

"...this list is far from complete. In fact, it could be subtitled “the tip of the iceberg”. For every inquest report that I was able to include, there was at least another where toxicology was completely excluded from the report, or where medication was hidden behind phrases such as “she was being treated for depression” or “he saw his GP”."

I was reading one of Brian's posts earlier about Coroner Ian Smith. Smith became famous in 2004 when he spoke out about antidepressants during the inquest of a local writer who had hanged himself “out of the blue”.

Smith had heard evidence during the inquest that the local writer was in the course of switching medication from Effexor (Venlafaxine) to Seroxat. To make the transition, he had gradually stopped taking Effexor and had been taking Seroxat for 11 days when he died.

In his summation, Smith pressed for more research into the antidepressant/suicide link as he had previously held two inquests where the person/s had been switching medication.

In 2008 Smith hit the news again.

In March 2008, at the inquest of a retired bank manager, Mr Smith spoke of a link between antidepressants and suicide:

One of Cumbria’s coroners is to contact drug authorities because he fears people are killing themselves after taking antidepressants.

Ian Smith is to write to the Committee on the Safety of Medicines – an independent advisory body …

… Mr Smith told the inquest he knew of several other suspected suicides involving the same group of antidepressants, known as selective serotonin re-uptake inhibitors (SSRIs).

He said: “I have to say this is probably the fifth, if not sixth inquest I’ve heard within a period of three years when somebody either just going on to Citalopram or Seroxat, or coming off it, have killed themselves one way or another, totally out of the blue, totally without expectation, without a history of suicidal thoughts in the past.” 

The following month, Mr Smith conducted the inquest into the death by hanging of a farmer.

He … criticised the use of antidepressants and expressed concerns over a pattern of people taking their own lives days after being prescribed the drugs …

Coroner Smith was right, although contacting the Committee on the Safety of Medicines [CSM] would have been frivolous. My experience of the CSM is that they are about as effective as trying to slam a revolving door.

In 2004 the, then, chief executive of Mind, Richard Brook resigned from the Committee after he was told by the British drugs regulator, the MHRA, not to reveal the Committee's findings that Seroxat had, for years, been prescribed by doctors in an unsafe dose and that the regulators had the evidence in their possession for more than 10 years. The MHRA threatened Brook with prosecution if he went public, he basically handed them the middle finger and went public anyhow. [1]

What the MHRA were asking of Brook was to keep secret from the public that GlaxoSmithKline's Seroxat was being prescribed in unsafe dosages. The MHRA, who remember carry the tagline, "Safeguarding human health", had knew this for ten whole years but decided, in their infinite wisdom, that this information would be best kept under lock and key, in other words they didn't see that releasing this information would safeguard human health. Perverse kind of thinking, wouldn't you say?

Not so perverse when you learn three things.

1. The MHRA are entirely funded by the pharmaceutical industry

2. The Chairman of the MHRA at the time had previously been employed by GlaxoSmithKline.

3. The Head of Licensing at the MHRA was former world safety officer at GlaxoSmithKline, one of his interests whilst working for Glaxo was the antidepressant, Seroxat.


Anyway, talking or writing about the MHRA always leaves a bitter taste in my mouth.

AntiDepAware is a must read. It will open your eyes to the closed eyes of Coroners.

The home page is HERE, recent posts are on the right hand side.

Bob Fiddaman



[1] The riddle of the drug regulators [Link]

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