Stephen O’Neill became anxious in 2016 and was given Sertraline. This caused an immediate toxic reaction that killed him, The doctors treating him invented a fictitious mental illness and both they and the coroner found it convenient to blame this fiction for Stephen’s death. See The Death of Stephen O’Neill and related posts.
The coroner and doctors all but laughed at the idea that the Doxycyline, a serotonin reuptake inhibiting drug, Dr Brannigan had given Stephen a few weeks beforehand might have produced the anxiety that led Dr Brannigan to prescribe Sertraline – not a treatment approved by MHRA or NICE Guidelines for Doxycycline toxicity. To recognise the link would have entailed recognising that they missed something sitting right in front of them.
A month after Stephen’s inquest, an horrific death of a young woman grabbed the attention of many people, not just in the UK. The drug she was on – doxycycline – was immediately in the frame. I was asked to provide a report and another coroner had to come to a conclusion. Could he find a Sanity Clause?
Doxycycline
Tom Osborne
HM Senior Coroner
City of Milton Keynes
March 16th 2020
Dear Mr Osborne
You have asked me to prepare a report on the possible effects of doxycycline on AC taken by her for malaria prophylaxis when undertaking a field trip in 2019 as part of her university studies.
Background Expertise
I am …
Background to AC’s Case
By way of background materials, you have provided me with
AC’s Medical History & Death
It appears from her medical records and the statements from her university supervisors that AC was a well-balanced and healthy young woman. She appeared well suited to the project she was undertaking and, barring an accident, there was little reason to think anything would go wrong and no reason to suspect the eventual outcome.
Suicides in women of this age are rare. Suicides in women of this age with no history of mental illness are vanishingly rare. There appear to be no financial, legal, relationship or other factors in this case pointing to any increase in risk and a lot of factors protective against suicide.
The statements of – several people – point to a change in AC’s mental state in the days immediately prior to the event. She appears to have had an increase in anxiety amounting to paranoia at several points, lability of mood, and what XY described as features of catatonia.
A’s mental state on both the day before and the day of the event appears to have been confused and distracted. The changes were such that they seem likely to have contributed to the event and it is difficult to see any reason for the event other than these changes.
Determining Causality
When it comes to determining what has happened in an event like this, the medical process is very similar to the judicial process. The details of an event and those leading up to it are examined for possible explanations and the person in question, if present, or witnesses, are examined and cross-examined to establish the most likely explanation. This counts for more than any supposed science.
In this case, based on the risk profile, and the descriptions offered by those closest to AC, the most likely explanation is that AC entered a toxic state and became delirious. This seems to be the explanation that those looking at the events at close quarters appear to have reached.
Toxic states arise primarily from physical causes such as infections, physical illnesses, drug treatments or other medical interventions. Extreme psychological shocks can also give rise to a “functional” delirium.
In this case, there is no prior evidence for an infection or other physical illness, and it is not possible from the autopsy to establish whether there was an unrecognised physical disorder.
There are no reports of a psychological shock or at present reason to suspect one.
There were two changes of drug treatment in the weeks prior to the event, one involving X and the other her use of doxycycline for malaria prophylaxis.
X
Seems extraordinarily unlikely for these reasons
Doxycycline
AC was also prescribed doxycycline, a tetracycline antibiotic commonly used for malaria prophylaxis, for the treatment of acne and for other infections.
She appears to have been aware that doxycycline can sometimes cause difficulties, and therefore took some test doses for approximately a week prior to leaving. She appears to have had some increase in anxiety and sleep difficulties but after reporting these to her parents she opted to stick with this treatment for her trip.
It appears that she took 11 doxycycline tablets, which is consistent with taking her medicines as she had been initially supposed to take them. Toward the end, she had apparently been advised to stop taking doxycycline, but it appears she did not stop, perhaps because she didn’t register the advice and was not registering much.
She may have been offered Nytol, diphenhydramine, to take as a sleep aid in the last few days but does not appear to have taken these tablets.
During the 11 days taking doxycycline, AC moved from being calm and confident to nervous and lacking in self-confidence. These changes are consistent with a drug induced behavioural toxicity. Her changes in mental state were marked in both nature and severity and sufficient to contribute substantially, even entirely, to the events that led to her death.
My impression is that a majority of observers looking at this scenario, with X labelled Factor A, and doxycycline labelled Factor B and other possibilities labelled Factor C would come to the conclusion that Factor B had likely played a part in AC’s death.
There is an extra element in this case that points to doxycycline. It appears that AC had tried it for a few days before leaving the UK and it caused some changes consistent with the changes she later displayed. This appears to offer a case of Challenge, De-challenge and Re-challenge (CDC).
When assessing a drug effect, CDC offers the strongest cause and effect evidence. This is a Christmas tree lightbulb approach to causality. Almost everyone will have had the experience of attempting to start old-style (pre-LED) Christmas tree lights after they had been put away for a year. When the lights failed to work, the standard procedure was to unscrew each bulb in turn and if the lights came on when a particular bulb was unscrewed and went off again when that bulb was screwed in again then this was taken as conclusive evidence that this bulb was the cause of the problem. The answer was to unscrew that bulb completely and leave the light set one bulb short or else substitute a new bulb.
CDC operates in the same way and AC’s case appears to offer an instance of this. Her prior test of doxycycline may in fact have inadvertently set her up to have a more rapid onset of an adverse response to doxycycline that she appears to have been predisposed to than she might otherwise have had.
There is one further element that may have played a part – Nytol. This drug is an antihistamine with serotonin reuptake inhibiting properties. While it is often used for sedation, it can cause the kind of agitation that selective serotonin reuptake inhibiting (SSRI) antidepressants can cause. Doxycycline also has serotonin reuptake inhibiting properties and people who become agitated on an SSRI may also become agitated on doxycycline and vice versa.
Doxycycline and Behavioural Events: Data
Making a diagnosis involves deciding which pattern (Gestalt) is most appropriate and the doxycycline pattern fits best and is likely to be the explanation most people would reach for other than those who find it difficult to believe that an “antibiotic” could cause a problem like this. There are two key elements in the pattern to note – one is the background difficulties consistent with the eventual outcome that is more evident with doxycycline and the other is, all things being equal, that a drastic outcome like this is more likely to occur in a shorter time-frame on a drug than a longer one.
When adverse events happen on drugs, doctors and increasingly other healthcare professionals and more recently those affected themselves can report to regulators such as the Food and Drug Administration (FDA) in the USA or the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK. The FDA has the largest body of easily accessible reports
As of late 2019, the data for suicidal events and suicide-related events on doxycycline in OpenFDA data is shown below. Close to 1/3rd of reports on doxycycline are for behavioural events. These reports primarily come from doctors and are sent through companies to FDA. Roughly 1/6th of MHRA reports on this drug are for similar behavioural events – again primarily from doctors. These reports concern patients taking this drug for acne, malaria prophylaxis and other infections.
FDA reports – Doxycycline
Terms included in each group
This profile of effects on doxycycline likely arises in part because many of those reporting have been prompted to report by their surprise at a suicidal or agitated reaction on an “antibiotic”. The proportion of such reports on doxycycline is higher than the proportion for many drugs carrying warnings about suicide risk.
Another point to note though is that the designation of a drug as antibiotic or antidepressant is somewhat arbitrary. Prozac (fluoxetine), for instance, among the best-selling antidepressants, has antibiotic properties and doxycycline inhibits serotonin reuptake like Prozac does and can cause emotional numbing as Prozac and other SSRIs can and dependence and withdrawal reactions as this group of drugs can.
There is another dataset stemming from the use of isotretinoin (Accutane) for acne:
Sundstroem A, Alfredsson L, Sjoelin-Forsberg L, Gerden B, Bergman U, Jokinen J. Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study. BMJ 2010; 342; c5812.
This paper carried the image below. All details of the data that went into this graph can be found in the published paper. The authors argue these figures indicate that acne leads people to commit suicide and therefore the suicide risk from isotretinoin can be discounted. This interpretation hinges on a view they offer that there is no signal that tetracycline antibiotics cause suicide – most people with acne will be given doxycycline or other tetracycline before being given isotretinoin. In the light of the FDA data above, this figure appears to offer strong evidence that doxycycline causes suicide/suicide attempts, as strong as the data for isotretinoin, bearing in mind that a proportion of these patients will not have been given doxycycline.
Doxycycline and Behavioural Events: Accounts
My interest in the issue of doxycycline and suicide was stimulated around 2012 by requests to write two reports for inquests after suicides on doxycycline and by witnessing a colleague given doxycycline, unbeknownst to me, become agitated on treatment.
This led to a publication in BMJ Case Reports headed Doxycycline and Suicidality. (Atigari OV, Hogan C, Healy D. BMJ Case Rep Published online: doi:10.1136/bcr-2013)
The cases are outlined here.
Case A
This is the case of a 19-year-old man, Mr. A, the youngest of four siblings from a happy home, with a stable social life. He was easy-going and intelligent. Mr. A had no history of mental disorder, and no history of alcohol or substance misuse. He had an early childhood history of mild asthma, allergic rhinitis, giardiasis, hives and allergic reactions with resultant swelling of his fingers and toes. The only family medical or mental history of note is that Mr. A’s eldest brother had reported severe anxiety symptoms after being commenced on doxycycline for malaria prophylaxis and another brother had developed similar symptoms on doxycycline for dermatitis which resolved after discontinuation of the medication.
Mr. A developed perioral dermatitis and was commenced on doxycycline 50mg BD six days prior to his death. He was not on any other medication. Four days after this, he went out socializing with friends and nothing unusual was noticed in his behaviour. On the night before his death, he engaged in sports with friends.
Later in the evening, he had a discussion with his parents about his future and they indicated they thought he was spending too much time on facebook and socializing. He accepted this and indicated he would limit his facebook usage in the next academic year to a set amount of time per day. His parents also had similar conversations with his brothers in relation their academic courses. Mr. A may have been a little bit more quiet than usual but nothing untoward was noticed.
On the day of his death, he had a normal morning at home with his family and exchanged innocuous text messages with his friends. He sent a text 17 minutes before his death to his friend to bring some whites for him to the cricket match. He then sent a text to the girl he liked, which read “wake up it’s nearly midday”. Within five minutes of this text, he jumped off a building at his former school, which is located close to his family home. Neither family nor friends had noticed any warning signs and no letter of intent to the possibility of a suicide has been discovered.
Following the death of Mr. A, the family came to an understanding that the medication prescribed in the cases of his older brothers, aforementioned, was possibly doxycycline.
In the autopsy report there was no alcohol or illicit substances detected in Mr. A’s blood or vitreous humour. Genetic testing of Mr. A revealed CYP2C19*2 heterozygote genotype associated with diminished cytochrome p450 enzyme activity. However, there was no method available in the laboratory for the analysis of doxycycline in the body.
Case B
This is the case of a 33yr old health professional in a stable relationship with her family including her sisters and mother. She had no history of mental disorder, alcohol or substance misuse. She has a history of mild acne for the last nine years. She has no other medical history of note.
Following a recurrence of her acne she was commenced on doxycycline 200mg stat, and then 100mg OD. The tablet gave effective relief for the acne. However, she developed nausea and headache on the second day of treatment. There was a feeling of disinhibition in her interaction with others, which she found liberating. This quickly developed into instability in her mood; fluctuating rapidly between irritability, anxiety and low mood. She became withdrawn, detached and began to ruminate over minor occurrences. By the third day she privately began to consider suicide as a solution to end her perceived problems.
Ms. B continued taking doxycycline for the next few days and the suicidal ideation, including thoughts of crashing her car got worse. She stopped treatment; she later attributed her stopping to luck. Ten days after discontinuation of doxycycline her mental state had returned to normal without any treatment with psychotropic medication. She remains well three months after discontinuation of the medication.
Afterwards she analyzed her circumstance with the help of family, and friends to determine if any occupational, family or social stressors could have precipitated or maintained the change in her mental state. None were identified.
Case C
Mr. C was initially put on doxycycline for mild acne; at the age of 18 years. He had no personal history of a mental disorder and was on no other medication. His sister was being treated for social anxiety. He had completed mechanics pre-apprenticeship and was employed part-time.
Mr. C took doxycycline 50mg per day over a period of a year. He felt unwell on it, and appeared “down” at times, and walked out of a job he appeared to be enjoying. This led his mother to talk things through with him but without either making a connection between his mood and his medication. He stopped treatment in August 2011. His mood brightened. He resumed work and began saving for a holiday.
He restarted doxycycline in February 2012, as his acne had returned. At this point he was apparently dispensed 100mg medication in 50mg packaging. He again began to have intermittent periods of low mood in the absence of any identifiable psychosocial stressors, which he reported to his mother. He again left his job. Eight weeks after restarting doxycycline and two days after leaving work he committed suicide by hanging.
RxISK.org
With colleagues, since 2012, I have been running an adverse event reporting website – RxISK.org. In 2018, we had 16 reports of suicidality or agitation on doxycycline consistent with the reports in Cases A-C. In 2019, we had 11 such reports. This year (2020) we have had the following 7 reports in January and February.
- A
- B
- C
- D
- E
- F
- G
Finally, there is currently a petition on Change.org called Doxycycline causes suicide in teens put there by Tara McCarthy after her 13-year- old son, Damein, committed suicide when put on this drug for acne. It has been signed by over 6,600 people.
Suicidality on Doxycycline
Doxycycline is an effective broad-spectrum antibiotic that is well tolerated by many people.
In the case of those who do not tolerate it, there appear to be two mechanisms that can lead to suicide. The most common mechanism is the induction of a toxic state that produces a delirium. By delirium here is meant a clouding of consciousness so that the individual is not registering their environment properly and behaves inappropriately in it.
These toxic states, whether caused by drugs or illnesses, are commonly accompanied by a degree of anxiety or agitation as can be seen in viral infections for instance. In the case of antidepressant and antipsychotic drugs, there is a word for this drug induced agitation – akathisia. But it is recognized that these drugs also cause a state more like AC which is commonly termed “psychotic”. The term delirium would probably be more appropriate in most instances than psychotic.
It is generally accepted that people in delirious states are not responsible for their actions. In the event of assaulting and even killing someone, while in such a state, such individuals have an absolute defense against a charge of murder. In the same way, death while in such a state would not ordinarily be viewed as a suicide any more than stepping out from a 55th floor window while under the influence of LSD would be regarded as a suicide.
The second mechanism involves an induction of emotional numbing that can lead to disinhibited or impulsive behaviour in someone who otherwise might appear to be in a state of clear consciousness. This appears to have been the element linked to the death of Case A above and the death of Damein McCarthy in the Change.org petition.
People who develop emotional numbness can also be agitated on treatment – somewhat confusingly perhaps there may be both anxiety and anxiolysis present at the same time.
Both delirium and emotional numbing may have been involved in AC’s case but a delirium seems to have been the predominant element.
Report to Regulator
The regulators for drugs, such as MHRA in UK, do not ordinarily investigate a death like AC’s in the manner that an inquest can. Regulators record suicidal events and their association with certain drugs without checking out the medical history and other details of the person in question and without making a judgement as to whether the death was more likely or not linked to the drug.
Reporting the results of an inquest to the regulator where a determination that it is more likely than not that this death was linked to this drug, if that for instance is the result of this inquest, can make an important contribution to wider patient safety.
It may encourage the regulator to request companies to add sufficient details to the label of their drug, in this case the many forms of doxycycline currently on the market. This is not a move aimed at reducing the use of doxycycline but rather aimed at putting a person who may be on treatment and adversely affected in a better position to understand what is happening to them. Or to put the relatives of someone affected such as her parents, in a better position to advise those who were looking after A not just to ask her to stop taking the drug but to ensure that all tablets were put beyond her reach.
This proposal aims at building confidence in the use of doxycycline rather than the reverse.
Mr Osborne’s Conclusion
How, when and where and for investigations where section 5 (2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by his or her death.
On the 25th of July 2019 the deceased open the door of a light aircraft that was flying from
Anjajavay to Antananarivo in Madagascar and fell to her death. She was a student from
Cambridge University carrying out research on the island. She had taken doxycycline as an
antimalarial medication and it is believed that she suffered a psychotic/delirium event that led to her behaviour and death.
Conclusion of the Coroner as to the death
Accident
The coroner has intimated he will be filing a regulation 28 report on this case, noting the effect of the drug.
Thank you for this Masterclass in the preparation and presentation of EXPERT Medico-legal,
evidence-based-evidence.
We read, and listen to so much ‘evidence-debased medicine’.
It was no accident. It was horrific. Akathisia is horrific.
The ‘Jungle’ of the ‘SS’ …
A touch of Mowgli..
Instead, the coroner ruled (using an anachronistic phrase not often heard nowadays) that Stephen
“took his own life while the balance of his mind was disturbed.”
http://antidepaware.co.uk/the-system-is-not-listening/
‘unless the medication she was put on disturbed the balance of her mind. But what does ‘disturb the balance of your mind’ mean?
Editorial note: In 1962, Sylvia Plath committed suicide a week after going on phenelzine, an antidepressant. She had two young children, making her death close to inexplicable – unless the medication she was put on disturbed the balance of her mind. But what does ‘disturb the balance of your mind’ mean?
In this account, another Sylvia put on doxycycline gives one of the best accounts there is of how easy it can be to slip away. Several weeks ago a RxISK story outlined the data linking doxycycline to suicide. This account is certain to make that data seem much more terrifying.
https://rxisk.org/suicide-is-painless-sylvias-story/
“It’s frightening to think that a tablet I take for acne can make me want to take my own life. It’s even more frightening that I nearly didn’t make the connection.”
In 2013, Dr David Healy published a list of “Drugs that can trigger and cause suicide or homicide”
http://antidepaware.co.uk/other-prescription-drugs-linked-to-suicide/
Anti-Infectives: Mefloquine [aka Lariam]; Doxycyline [Doryx]; D-cycloserine [Seromycin]; Fluoroquinolones [Levaquin, Cipro]; Oseltamivir [Tamiflu].
“The experience wasn’t fatal in my case, but others haven’t been so lucky.”
Stephen’s voice called the SS – the Secrets of Seroxat and the Secrets of Sertraline – the doctors were flailing around … with behavioural toxicity
https://www.news18.com/news/world/student-who-jumped-to-death-from-madagascar-plane-was-taking-anti-malaria-medication-2308513.html
…following a course of doxycycline. …
My first experience of akathisia was from one tablet of Sertraline and one tablet of Nytol. Within hours was in an horrific state that I couldn’t explain with words. In the early hours I was in the A&E of a local hospital pacing everywhere – a junior doctor tapped both my knees and then told me there was nothing wrong with me and that she would write to my GP and discharged me. That letter got me a visit from a psychiatrist, nurse and social worker more psych drugs and a decent into utter horror and vile abuse in a psych ‘hospital’ which went on for a year. I later discovered that both Sertaline and valerian – found in Nytol – inhibit/block important CYP450 enzymes. And if you think it’s over when you are finally discharged think again, you are never free of psych. You are now primed for further bouts unless you are very very careful. It’s not just a question of staying off psych drugs – ofcourse you can’t do that if a psychiatrist get’s hold of you, you’re getting the drugs. You have to be very aware of any stresses and situations that can cause anxiety to become an issue.
If the harm done by antidepressants were acknowledged by coroners etc. it would undermine social control. Those not conforming (e.g. social behaviour or taking time off work) are treated with the sledgehammer of drugs because it’s the quickest way to control behaviour. The ‘mental health’ system (including GPs) is about power, not health (the deceit of the medical language-‘health’ ‘diagnosis’ ‘treatment’ regarding emotional distress/ behaviour is Kafkaesque).Victims of the system are ‘heads on sticks’ to keep the rest of society in line. (That industries and professions feed off them is secondary). The individual and understanding real causes of distress/behaviour is irrelevant.
To control behaviour, victims are degraded by ‘diagnosis’ (not diagnosis at all and unscientific) which involves ignoring real causes of distress and lying (the lie of the ‘chemical imbalance’ in psychiatry and the lie in clinical psychology about causal false beliefs) which means the person is seen as having no agency and should not be listened to or believed. (Despite no proper mental capacity assessments ever taking place). Assessment information is distorted to fit with these erroneous theories of cause. Since no one wants the shame of such (loaded) diagnoses, the latter serve as an effective deterrent for those who may stop conforming. These false diagnoses are used to coerce patients into taking drugs. Drugs are ‘chemical straightjackets’ for emotions/behaviour but also serve to invalidate (punish) consideration of real but inconvenient causes of distress. For the depressed, being emotionally numb does not prevent them working (but does prevent any agency in addressing real causes of original distress). In the mental health system coercion ultimately takes, in the case of confinement (sans legal rights), the form of ‘psychiatric rape’ – see psychiatrist Thomas Szasz) – clearly punitive. Psychiatrists know drugs harm, continuing to coerce when drugs are clearly causing e.g. heart problems (GPs are involved in this) so they are unlikely to be concerned about akathisia. (It is not just that acknowledging side effects would remove power to use drugs – side-effects are also part of the punishment/deterrent). In ‘hospitals’ akathisia controls social behaviour by increasing focus on its torture, so making people less challenging about their inhumane treatment – so doctors ignore it. Pacing associated with akathisia is like a ‘tarring and feathering’ (patients look ‘mad’ after taking medication, not before)-for some psychiatrists this is just part of the punishment. Even if treatment is provided for akathisia it’s only to persuade the person to keep taking the offending medication (although persuasion is little used before force). If the person manages to stop medication, the treatment for akathisia is immediately withdrawn, despite the evidence that akathisia persists. These attitudes from the mental health system pervade GP practice.
Guidelines, by omitting side effects help deceive the public that their emotional wellbeing and health matters.
It is the myth of mental illness and how this serves powerful groups- state, employers etc by justifying the use of punitive measures as the most effective and efficient form of social control that needs to be challenged. Maybe the state’s response to coronavirus will help people realise that their health per se is irrelevant and that the mental health system /GPs threaten us all.
In 1920 Karl Binding (academic lawyer) and Alfred Hoche (psychiatrist) wrote a treaty: Die Freigabe der Vernichtung lebensunwerten Lebens (“Allowing the Destruction of Life Unworthy of Living”) used by the Nazi’s to justify their Aktion T4 mass murder program. In this they seek to rationalise and normalise state backed murder using considerations of the nature of suicide and the debasement of humans:
“Proof of the illegality of suicide could only be obtained from the exact proof of the positive law on homicide. But the material is missing wherever suicide is not punishable or is otherwise unequivocally identified as a crime. Or it could result from legally established premises.”
“So not only is there no evidence for the crime nature of suicide, but even today no suicide and none of his judges even remotely see a forbidden act in suicide and really put it on a line with murder and homicide.”
Karl Binding
Now think of that today in the context of psychiatric high dose polypharmacy drug toxicity inducing Akathisia/Toxic Psychosis causing suicide and homicide (see Catherine Clarke) and the Cytochrome P450 gene test that can predict an individuals inability to metabolise and the 200 or so drugs that can cause Akathisia/Toxic Psychosis (see David Healy) and the fact that almost no one in the UK is given this test that has been around for more than twenty years, which used in a court of law could pretty much prove the ‘crime nature of suicide’. No wonder that psychiatry doesn’t want this test for everyone.
And then this kind of human debasement thinking:
“The most essential thing is the lack of the possibility to become aware of one’s own personality, the lack of self-confidence. The spiritually dead are on an intellectual level, which we only find deep down in the animal series, and the emotions do not rise above the line of the most elementary processes linked to animal life.”
Alfred Hoche
Now fast forward to our time:
“The thing about acute serious mental illness is that people are not behaving badly, they are beyond any moral consideration, they are behaving in a very seriously mentally disorder way, it always reminds me of when they use to prosecute pigs for eating apples in your orchard.”
Forensic psychiatrist Tony Maiden 2015
In 1939 Gerhard Kretschmars father sent a request to Adolf Hitler to be allowed to put his disabled son ‘to sleep’. Hitler sent his personal physician Karl Brandt to administer a lethal barbiturate dose. Days later, 15 psychiatrists were ordered to Hitlers Chancellery and told a secret forced euthanasia program was to be rolled out code named T4, after the street address of it’s activities. Six ‘hospitals’ were used to mass murder psychiatric patients at: Brandenberg, Grefeneck, Hartheim, Sonnenstein, Bernburg and Hadamar and later 300 other psychiatric institutions.
These centers served as training for the Schutzstaffel (SS) who later constructed larger killing centers (Auschwitz, Treblinka, etc.) German psychiatrists tried a number of methods to implement their T4 ‘euthanasia’ program – barbiturate injections, including a sub-lethal dose to induce pneumonia just so the psychiatrists could state pneumonia as a cause of death to the family, firing squads, starvation or freezing, gassing with truck exhaust, gassing with CO gas developed by psychiatrist Werner Heyde M.D.and used in the holocaust. The psychiatrists had gas chambers constructed in Mental Health institutions made to look like shower rooms where MH patients were killed, their bodies dragged out, their brains cut out and their bodies burnt.
The SS the most heinous and murderous Nazi criminals were taught by psychiatry – a so called medical profession – how to mass murder in these 6 ‘hospitals’ the techniques were then used in the holocaust, indeed it was an extension of what psychiatry did. Prior to this 1934-1939 the psychiatrists forced 400,000 sterilizations. Psychiatry had brought eugenics to life in Germany. Admired by Hitler, America had already set up eugenics organisations looking to implement forced sterilizations: American Breeders Association, Human Betterment Foundation, The Race Betterment Society, America Eugenics society, Immigration Restriction League and the most important of all – The Eugenics Records Office at Coldspring Harbor Long Island New York founded by Mary Harriman and Charles B. Davenport, funded by Harriman rail baron wealth and later The Rockefeller Foundation and Carnegie Institute.
Also by the 1920’s Rockefeller was funding German eugenicist psychiatry – The Kaiser Wilhelm Institute of Anthropology of Human Heredity & Eugenics.(KWI-A) The director was eugenicist psychiatrist Ernst Rüdin, a principle architect of mass sterilization and mass murder known as Aktion T4. Rüdin along with many other psychiatrists and fellow eugenicists Otmar Freiherr von Verschuer and Franz Josef Kallmann both directors of KWI-A were not brought to justice after the war. This happened because American eugenics $ power had funded German eugenics. In the horror aftermath of the concentration camps, the top German psychiatrists could hold a silver mirror to the Americans, during the the Nuremberg trials they could point out American eugenics funding to themselves and to their own US forced sterilization and probably the plans for eugenicide using gas chambers:
“Carnegie-supported 1911 “Preliminary Report of the Committee of the Eugenic Section of the American Breeder’s Association to Study and to Report on the Best Practical Means for Cutting Off the Defective Germ-Plasm in the Human Population.” Point eight was euthanasia. ”
“The most commonly suggested method of eugenicide in America was a “lethal chamber” or public locally operated gas chambers.”
The eugenicists/geneticists are particularly interested in twins, in their view, to study environmental social influence difference between them in relation to their shared genetic influence of traits.
In a letter to his wife in 1946 Allied investigator Leo Alexander wrote:
“It sometimes seems as if the Nazis had taken special pains in making practically every nightmare come true. Some new evidence has come in where two doctors in Berlin, one a man and the other a woman, collected eyes of different colour. It seems that the concentration camps were combed for people whose one eye had a slightly different color than the other. Who ever [sic] was unlucky enough to possess such a pair of slightly unequal eyes had them cut out and was killed, the eyes being sent to Berlin. This is the carrying out into reality of an old gruesome German fairy tale which is included in the Tales of Hoffmann, where Dr Coppelius posing as a sandman comes at night and cuts out children’s eyes when they are tired. The grim part of the story is that Doctors von Verschuer and [Karin] Magnussen in Berlin did prefer children and particularly twins. There is no end to this nightmare, at least 23 are being tried now and, I trust, the others will follow later.”
An appalling irony that Rockefeller who funded KWI-A – Karin Magnussen also worked at KWI-A – also recently funded the Museum of Modern Art New York to the tune of $400 million – considered one of the most important visual (eyes) art institutions in the world.
If there was ever a time to abolish and outlaw psychiatry for major crimes against humanity it was after WW2. But what happened was all around evil, monsters the like of Donald Ewen Cameron – he of Project MK Ultra torture methods – techniques born of William Sargent British monster brain butcher ‘esteemed’ psychiatrist – assessing the German ‘esteemed’ psychiatric monsters in Nuremberg at the request of UK’s Tavistock psychological warfare set-up.
So what we have now is psychiatry unchecked and obsessed with drugging people. The three Sackler family ‘esteemed’ brothers Arthur, Mortimer and Raymond were all psychiatrists, also massively funding the cream of the art world.
Massachusetts Attorney General Maura Healey, sets out what the Sackler family did via their Purdue Pharma:
“1.Dangerous opioid drugs are killing people across Massachusetts. Prescription medicines, which are supposed to protect our health, are instead ruining people’s lives. Every community in our Commonwealth suffers from the epidemic of addiction and death.
2.Purdue Pharma created the epidemic and profited from it through a web of illegal deceit. First, Purdue deceived Massachusetts doctors and patients to get more and more people on its dangerous drugs. Second, Purdue misled them to use higher and more dangerous doses. Third, Purdue deceived them to stay on its drugs for longer and more harmful periods of time. All the while, Purdue peddled falsehoods to keep patients away from safer alternatives. Even when Purdue knew people in Massachusetts were addicted and dying, Purdue treated doctors and their patients as targets to sell more drugs. At the top of Purdue, a small group of executives led the deception and pocketed millions of dollars.
3.On behalf of the Commonwealth, the Attorney General asks the Court to end Purdue’s illegal conduct and make Purdue and its culpable executives pay for the harm they inflicted in our state.”
I’ll leave you with a quote from UK home treatment team consultant psychiatrist Dr Derek Tracy also part of the UK Advisory Council on the Misuse of Drugs and advocate of “Evolutionary” Psychiatry 2019:
“Most people who take drugs are not particularly harmed by them.”
The easy life
The wealthy life
of The Coroner under Pharmagods of Prey.
What about those lovely people, old and young…Pharmagods of Prey do not care.
They try to justify their prescribed poisons and devalue the beautiful people now gone.
How dare they!
The Pharma Industry like Psychiatry is an Industry…
Would one put some tainted oil into their car…No…But it seems to be OK for doctors to prescribe toxic drugs to human beings…
Pharmagods of Prey are interested ONLY in their profit margins…
Rest in Peace the Lost Souls as your realise now that the drugs do exactly what it says on the Pack ‘Suicide Ideation’.
Governments need to wake up to Protect the vulnerable…but will they as Pharma Colonies take control everywhere!
David – this describes changes have been made since the cases you documented in 2011 – is there any hope for optimism resulting from the regulation 28 report in the last case you have described -as it happened after 2015? (There are examples of reports andoutcomes on this site)
Re What Do You Know’ historic FOI requests…………..
‘As you may be aware from 1 April 2015 CQC is the lead enforcement body for health
and safety incidents in the health and social care sector
DEATH REPORTS FROM CORONERS
WHAT IS A REGULATION 28 REPORT?
Regulation 28 of the Coroners (Investigations) Regulations 2013 gives Coroners a
power to issue a prevention of future death report during but most commonly at the
conclusion of an inquest.
Regulation 28 Reports (R28 Reports) are issued by Coroners when the Coroner
remains concerned that, despite evidence given by witnesses including the registered
provider, similar incidents could reoccur.
A R28 Report is not a record of historic concerns related to the death; it is a court
record of current serious concerns. R28 Reports contain important and credible
intelligence for CQC. They must be taken seriously as these reports are about risk
and inform our management of risk.
R28 Reports are not exclusive to deaths in the health and social care sector but apply to
all inquests.
Suzanne
Don’t hold your breath – there have been lots of Regulation 28 reports about Antidepressants that get dismissed with a phrase like the wonderful MHRA are keeping all this under active review.
David
Griseofulvin was prescribed to me and within a week I became suicidal, tired, low energy but not depressed. I could not stop looking at option to end my life. My wife found out the link of the anti-fungal and suicide. I stopped it and 2 days later the symptoms stopped abruptly. I could not believe it and several days later re-started Griseofulvin, within 3 days the suicidal came back and a day and a half after stop, it suddenly stopped.
I thorough search finally suggested possible mechanism: dopamine synthesis inhibition that eventually caused weakness of anti-gravitational muscles followed by severe apathy and loss of survival instinct. Then I found that low dopamine will affect Glutamate system and trigger the suicide. That is the current idea of Glutamate and suicide and ketamine…
“The arrested suspect, Khairi Saadallah, 25, had been diagnosed with post-traumatic stress disorder, depression and an emotionally unstable personality disorder.”
https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/treatment/
https://www.theguardian.com/world/2020/jun/28/screen-survivors-of-covid-19-for-ptsd-say-mental-health-experts
https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/treatment/
‘paroxetine and sertraline are licensed specifically for the treatment of PTSD.’
We can expect more horror shows.
request-677165-1e7d94f2@whatdotheyknow.com
20th July 2020
Disclosure Team
Ministry of Justice
102 Petty France
London
SW1H 9AJ
data.access@justice.gov.uk
Freedom of Information Act (FOIA) Request – 200715002
Thank you for your request dated 15th July in which you asked for the following information
from the Ministry of Justice (MoJ):
Can you please let me have information on Regulation 28 Reports with
reference to adverse effects and of deaths relating to psychiatric drugs?
Your request is being handled under the FOIA.
I have considered your request for information but I am unable to answer it without further
clarification. Section 1(3) of the FOIA does not oblige us to answer requests where we
require further clarification to identify and locate the information requested.
Please provide further detail on the information you are seeking. On receipt of this I will
continue to process your request. I should explain that Regulation 28 reports, i.e. Prevention
of Future Death reports are published by the Chief Coroner on the Judiciary website.
https://www.judiciary.uk/subject/prevention-of-future-deaths/
Whilst the Chief Coroner publishes these reports and the responses to them, they are
retained on a database with only limited search criteria. This does not provide for
identification of only those reports that related to deaths where psychiatric drugs were found
to be the cause.
Yours sincerely
Snipetts from UNHERD etc
The author speaks as though eugenics in Europe is a thing of the past. The British Psychological Society has held secret meetings in recent years to discuss eugenics They barred reporters. Conversely the past Editor of Medical Hypotheses was outed for expressing a controversial view about AIDS He has also stated that the ‘working class’ are less intelligent than – people like him.
Staff resign after Prof Bruce Charlton sacked over Aids article
00:26, 23 JUN 2010UPDATED 22:13, 25 JUN 2013
It is not the first time Prof Charlton has been at the centre of an academic dispute. In 2008 he claimed the working classes had lower IQs than wealthier people and should not be expected to win places at top universities.
THE SACKING of a North East professor over a controversial research paper has sparked an exodus of fellow academics
Bruce Charlton, a professor in Evolutionary Psychiatry at Newcastle University, was axed from his editorial role on the research journal Medical Hypotheses after he chose to publish an article about Aids by Peter Duesberg.
(Who decides what readers/citizens shoud read – Elsevier; medical journal editors, exclusive publications not accessible to everyone….)
In a controversial piece Prof Duesberg, who has previously claimed that the Aids death-toll in South Africa was exaggerated, suggested there was “no proof that HIV causes Aids”. The backlash from scientists was so fierce, Amsterdam-based publishers Elsevier issued Prof Charlton the ultimatum of adopting a new peer-review process at the journal or resigning. (Echoes of Cochrane..)
But Prof Charlton chose to do neither and defended his decision to publish the paper in the journal, which he said was a platform for studies that were “radical, interesting, dissenting, or sometimes amusing”. Following Prof Charlton’s dismissal, almost half of the editorial board at the journal resigned in protest. Last night Prof Charlton, who still works at Newcastle University, refused to comment on his sacking from the post, but in entries on his online blog he made no apology for printing the research.
He wrote: “For me to collude with prohibiting Duesberg from publishing, I would have needed to be 100% sure that Duesberg was 100% wrong.
“Because even if he is mostly wrong, it is possible that someone of his ability may be seeing some kind of problem with the current consensus about Aids that other people of lesser ability, that is most of us, are missing. (This view is echoed by David Healy blogs and publications)
“And if Duesberg may be even partially correct, it is extremely dangerous that the proper scientific process has been so ruthlessly distorted and subverted simply to exclude his ideas from the official scientific literature.”
It is not the first time Prof Charlton has been at the centre of an academic dispute. In 2008 he claimed the working classes had lower IQs than wealthier people and should not be expected to win places at top universities.
The board at the Berkely-based University has now concluded that Duesberg was not at fault and dropped a probe into the paper which was printed in July last year. But academics from across the UK have already quit their editorial posts at Medical Hypothesis, claiming the dismissal of Prof Charlton was unfair.
Among them was David Healy, reader in psychological medicine at Cardiff University, and William Bains, a biochemist and founder of consultancy Rufus Scientific.
A Newcastle University spokesman said: “The University is aware of this situation, but it is a matter between Dr Charlton and the publisher.”
Professor David Healy and colleagues have recently set up SAMIZDAT-HEALTH in order to get the truth published about issues no other publishers would touch. Including Elsevier . see Children of the Cure etc
From UNHERDSpotlight
How the establishment fell for eugenics
A shocking number of influential Britons used to think it necessary to wipe out ‘inferior’ citizens
BY PETER FRANKLIN
George Bernard Shaw: one of many eugenicists we haven’t yet cancelled.
Peter Franklin is Associate Editor of UnHerd. He was previously a policy advisor and speechwriter on environmental and social issues.
R. A. Fisher
Fellow 1920-26 1943-62
President 1956-59
The real problem here is that Fisher was not some isolated crank. He was part of the much wider eugenics movement of the nineteenth and twentieth centuries. It can’t be edited out of our intellectual history, because for many decades, and to a shocking extent, it is our intellectual history.
Eugenic ideas were deeply embedded within almost every facet of modernity — shaping the thinking of movements, organisations and individuals that are still venerated today as icons of science and progress.
Taking Fisher as a starting point, one can, in the manner of a crazed conspiracy theorist, trace the links between many of the biggest names in science, literature, politics and social reform. Except that there’s no conspiracy — it’s all on record: a dense web of professional and personal relations that define the intellectual life of the era.
For instance, Fisher had an important mentor and supporter in Leonard Darwin — the son of Charles and the President of the Eugenics Education Society from 1911 to 1929. The EES was the focal point of the eugenics movement — almost every eugenicist that I mention in this article was a member of it
The father of eugenics was Charles Darwin’s cousin, Francis Galton, who coined the word and laid down its pseudoscientific principles. He was instrumental in founding the EES in 1907 with the 21-year-old Sybil Gotto. The EES became the (British) Eugenics Society in 1924 and then, ……………….much later in 1989, the Galton Institute.
It should be said that the Institute has long repudiated its eugenic past. (Not that long)For instance this is what it’s website says in reference to Galton’s 1869 book Hereditary Genius:
It was indeed another time, but even so Galton’s prejudices were grotesque.
In Shaw’s infamous words, “the only fundamental and possible Socialism is the socialisation of the selective breeding of Man.”
Henry Asquith advocated compulsory sterilisation as an alternative to confinement — a “simple surgical operation so the inferior could be permitted freely in the world without causing much inconvenience to others.
Beveridge was no better. In 1906, he stated that “the unemployable” should be supported by state, but at the cost of losing their rights including “the franchise… civil freedom and fatherhood”. In the 1940s, at the height of his influence, he argued that child benefits should be paid at a higher rate to middle class than working class families to boost the birth rate of the former.‘ — a mixture of charitable action, social reform, finger-wagging moralism, class snobbery and, in many cases, outright bigotry.
“Birth control is not contraception indiscriminately and thoughtless practised. It means the release and cultivation of the better racial elements in our society, and the gradual suppression, elimination and eventual extirpation of defective stocks — those human weeds
the intelligentsia felt not compassion, but deep revulsion, for those less fortunate than they were. Take this 1915 diary entry from Virginia Woolf:
“we met & had to pass a long line of imbeciles. the first was a very tall young man, just queer enough to look at twice, but no more; the second shuffled, & looked aside; and then one realised that everyone in that long line was a miserable ineffective shuffling idiotic creature, with no forehead, or no chin, & an imbecile grin, or a wild suspicious stare. It was perfectly horrible. They should certainly be killed.”
The more progressive intellectuals may have subscribed to various schemes for the improvement of society, but that did not preclude the most dehumanising attitudes to individuals that they saw as beyond help. Even the self-declared socialists, who supposedly had the best interests of the working class at heart, perceived much of it as an obstacle to progress. As H. G. Wells complained:
“We cannot go on giving you health, freedom, enlargement, limitless wealth, if all our gifts to you are to be swamped by an indiscriminate torrent of progeny …and we cannot make the social life and the world-peace we are determined to make, with the ill-bred, ill-trained swarms of inferior citizens that you inflict upon us.”
This was also the Bureaucratic Age — a time in which technocracy had yet to understand its limits. Everything, not just the economy, was to be managed from the top-down by an expert class: “No consistent eugenicist can be a Laisser Faire individualist”, exhorted Sydney Webb, “he must interfere, interfere, interfere!”
Eugenics stood at the intersection of so many powerful intellectual currents — so why didn’t it triumph completely?’
(It maybe didn’t but the psychologoical Society has held meetings in secret, barring any reporters or publications, to discuss eugenics, perhaps by another name, in recent years. People with ‘disabilities’ are still being forcibly drugged,tortured by their ‘carers’ and locked up in UK institutions
Thousands of people across the globe are being sterilised by the use of psychiatric drugs which are known to effect fertility and ability to have children. They may not be called eugenicists but people who are prescribed them are predominantly described as ‘working class’ from ‘deprived areas’ doing ‘non essential work’ The charities and welfare schemes people are forced into are little more than the grotesque legacy of the so called ‘intelligensia ‘who perceive others as inferior and dispensible.
‘But all of that would be missing the point. After all, it’s not the madness of the dead we need to watch out for. ‘
the reporting of cause of deaths by prescription drugs needs to be included in the research – but not only relating to Covid. Could this be used in the petition being presented to Parliament right now to oblige Coroners to include which prescription drugs had been used by people before a suicide or other cause of death/
The BMJ
Covid-19: We need accurate and rapid reporting on deaths referred to the coroner
July 30, 2020
Rapid reporting of accurate statistics is essential for understanding the causes of deaths from covid-19 and identifying the best means of prevention. [1] However, in England, registering a death is delayed if the death is referred to a coroner. These delays can be substantial—weeks, months or years—if the coroner determines that an inquest is appropriate. Not even fact-of-death is typically registered with the Office for National Statistics (ONS) until the coroner has determined the cause of death. [2]
In contrast, these delays do not occur in Scotland, because fact-of-death must by law be registered with National Records of Scotland (NRS) within eight days of death being ascertained. At the time when a death is registered, the registrar informs the NRS if a doctor or the registrar has referred the death to the Procurator Fiscal. Referral to the Procurator Fiscal can also be made after a death is registered, but the NRS will not know about this.
On 13 May 2020, Scotland’s Lord Advocate issued new guidance on presumed covid-19 deaths. [3] Specifically, the Lord Advocate announced that the Crown Office and Procurator Fiscal Service will register and may investigate all covid-19 or presumed covid-19 deaths where the deceased “might have contracted the virus in the course of their employment or occupation” or “was resident in a care home when the virus was contracted.” The Lord Advocate’s decision is back-dated to apply equally to covid-19 deaths in those two categories that have already occurred.
According to data from the NRS, between 12 January and 24 May, out of 1,255 deaths referred to the Procurator Fiscal, which did not mention covid-19, and in people aged under 65 years with a declared occupation and not-retired, 109 of them were the deaths of healthcare or social care workers. By contrast, between 9 March and 24 May, for people aged under 65 years with a declared occupation and not-retired, out of 49 covid-related deaths referred to the Procurator Fiscal eight were the deaths of healthcare or social care workers.
Thus, the observed PF-referral-rate nearly doubled for covid-mention deaths of working-age health or social care workers during registrations to 24 May 2020 when compared to their PF-referral-rate for non-covid deaths since the start of 2020. Data for England are lacking on the number of covid-mention deaths of health and social care workers that have been referred to the coroner. [4] For this reason, we had appealed to National Records of Scotland for data that might shed light on this gap for England. Remember that, in Scotland, fact-of-death must be registered for all deaths within eight days. Based on data from Scotland, and assuming a similar referral practice in England, we believe that approximately 90 deaths of health and social care workers from covid-19 may have been referred to coroners in England and Wales. This is of concern if these deaths have not yet been registered with ONS, and therefore are not yet accounted for in official statistics
Information, including occupation, on covid-related deaths that are under investigation by coroners is urgently required from the Chief Coroner in England to draw clear occupational-risk inferences. Preparedness for a second wave of covid-19 should ensure that this coronial registration-gap is plugged and that at least some inquests conclude before the end of autumn. [6]
During a pandemic, an emergency system should be in place whereby the Office for National Statistics is informed immediately about any death referred to coroners so that fact-of-death is duly registered (as for all other deaths) even though the presumptive cause-of-death has yet to be confirmed.
Sheila M. Bird, for
Conflict of interest: SMB leads for the Royal Statistical Society on the need for legislation to end the late registration of deaths in England, Wales and Northern Ireland.
Another cover up – Shameful there is no mention of the drugs Clare Cutland took just before she committed suicide Presumably thebmj had the whole story including expert witness report by D H before publishing this If Clare Dyer had done her homework she would have seen they were mentioned by name so who decided to cut the whole truth and nothing but the truth… The ‘story ‘ was all over the newspapers at the time – so obviously that piece of information was deliberately omitted
with a convenient focus on the antibiotic
October 23, 2020 at 1:30 pm
News
Doxycycline: Coroner calls for MHRA to review side effects after student jumped from plane
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4102 (Published 22 October 2020)
Clare Dyer
A senior coroner has demanded action from the Medicines and Healthcare Products Regulatory Agency after a student who had taken an antimalarial drug jumped from a plane to her death.
Alana Cutland, 19, a natural sciences student at Cambridge University, was doing an internship in Madagascar when she had several attacks of paranoia.
A senior coroner has demanded action from the Medicines and Healthcare Products Regulatory Agency after a student who had taken an antimalarial drug jumped from a plane to her death.
Alana Cutland, 19, a natural sciences student at Cambridge University, was doing an internship in Madagascar when she had several attacks of paranoia.
She had spoken to her parents and was about to fly home to the UK after cutting her internship short in July 2019 when she travelled in the Cessna light aircraft. She opened one of the plane’s doors and, despite attempts by the pilot and the other passenger to restrain her, leapt from the plane.
An inquest into her death determined that the cause was “traumatic injuries following a fall from a plane” but heard that she had been prescribed doxycycline as an antimalarial drug.
Tom Osborne, senior coroner for Milton Keynes, wrote in his inquest report, “The deceased was prescribed doxycycline as an antimalarial 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. In my opinion action should be taken to prevent future deaths and I believe . . . your organisation [has] the power to take such action.”
Doxycycline is a tetracycline antibiotic that can also be used to prevent malaria. The National Institute for Health and Care Excellence website lists anxiety as a rare side effect but doesn’t mention psychotic reactions.
Coroners are under a duty to send reports, known as regulation 28 reports, to individuals or organisations they believe to be in a position to take action if their investigation reveals a risk that other deaths will occur in similar circumstances.
An MHRA spokesperson said it had been granted an extension to the deadline for replying to the coroner’s demand for action “in order to seek independent expert advice.” The spokesperson added, “We are currently reviewing the available evidence on the suspected association between doxycycline and psychotic disorder. This is because psychotic disorders are not currently a recognised side effect of this drug.
“We have informed the coroner that our review is ongoing, and any regulatory action will be communicated to healthcare professionals and patients. Malaria can be a very serious, sometimes fatal, infection. It is important that people travelling to areas that pose a risk of infection receive appropriate antimalarial prophylaxis.
“Doxycycline has been authorised for the prevention of malaria and also for the treatment of bacterial infections and skin disorders such as acne for over 50 years. During that time many millions of people have taken it. The balance of benefits and risks for doxycycline is considered to be positive. Patient safety is our highest priority so, as with all medicines, we keep the product information for doxycycline under review.”
This has echoes of what happens to people killed by medications
Landmark ruling that toxic fumes killed nine-year-old Londoner follows long campaign for truth
Sandra Laville
Sandra Laville Environment correspondent
Wed 16 Dec 2020 12.03 GMTLast modified on Wed 16 Dec 2020 17.28 GMT
S
Ella Kissi-Debrah died in February 2013 after a severe asthma attack.
Until now, the statistics on air pollution deaths have been presented in black and white – numbers on a page that estimate between 28,000 and 36,000 people will die as a result of toxic air pollution every year in the UK.
As Prof Sir Stephen Holgate told the coroner, behind the often-quoted statistics lie individuals whose lives have been cut short. “Every single number that goes into these studies is a single person dying,” he said.
Holgate paid tribute to the resilience of Ella’s mother, Rosamund Kissi-Debrah, for her tenacity, which on Wednesday helped to make legal history when for the first time air pollution was recorded as a cause in an individual death in the UK.
The last two years of Ella’s life were punctuated by severe asthma attacks that led to her collapse and admission to hospital almost 30 times. Her lungs collapsed, or partially collapsed, on five occasions, as she struggled to survive what the coroner heard was a form of asthma that flooded her lungs with fluid.
It was Holgate’s examination of these years, recorded in medical notes from a range of experts whom Kissi-Debrah turned to for help, that led to a pattern emerging.
Unlike most people with asthma, Ella’s attacks were not triggered by pollen or respiratory infections but something else. Holgate’s work exposed that pattern as a seasonal one: it was in winter when air pollution levels spiked that Ella was brought down with coughing fits, which triggered secretions in her lungs that in turn triggered her collapses.
The scale of the crisis was a public health emergency, the hearing was told, and the efforts of the authorities to tackle it were glacial.
But as she walked to school along the main road and sometimes the back streets, Ella and her mother were in ignorance of the damage the toxic air was causing. No one had told them
The first inquest into her daughter’s death in 2014 recorded that Ella had died in Februrary 2013 of acute respiratory failure. There was no mention of any environmental factors causing the fatal collapse.
“I got a call from someone who told me [that] in the two days around Ella’s death there were big spikes in air pollution locally,” Kissi-Debrah said. From there the evidence grew, and the case was taken up by the human rights lawyer Jocelyn Cockburn.
The first inquest into Ella’s death recorded that she had died of acute respiratory failure.
The first inquest into Ella’s death recorded that she had died of acute respiratory failure. Photograph: Rosamund Kissi-Debrah/PA
When Holgate produced a report for the family last year linking air pollution levels to Ella’s death, the attorney general quashed the first inquest.
Over the past two weeks a very different inquiry into what took the nine-year-old’s life has been played out in the coroner’s court.
This time government departments, officials from the local authority and the mayor of London were questioned about what they did – or did not do – to reduce illegal air pollution levels around the area Ella lived.
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Crucially, they were interrogated about whether they informed the public of the risk to their lives from the air they were breathing, and whether their failings might have breached Ella’s right to life.