This is part 2 of Spotlight on the Suicides.
In February 2017, I received the email below. The email address gave no hint of where it came from – it could have been any English speaking country but the word Trust in the second and fourth paragraphs suggested England.
The details seemed clear enough for me to respond that the coroner would have to request my input and I would need access to all the medical records of the man in question. And I asked where the emailer was based.
My family and I are hoping that you can provide us with an expert opinion in relation to my uncle’s suicide. Currently, we have requested an inquest into Stephen’s death and have provided the coroner with a file of documentation to support our concerns, that is, that Stephen died as a result on an adverse reaction to anti-depressant medication he was taking. To us, the evidence is clear cut. Stephen first took the medication on 16th June 2016 and within 6 weeks of suffering severe symptoms and constantly telling his family and professionals the medication had ‘done something to my head’ and begging for help, he was found hanging in his brother’s backyard.
We have also received a “root cause analysis report” from the Trust that confirms that prior to starting the antidepressant on 16/06/16 he had difficulty sleeping and possibly mild anxiety from time to time but no suicidal thoughts or depression. However, this is a draft report and we are due to meet with the Trust soon to discuss some gaps and information that has not been included, such as Stephen telling the crisis team that during first day or two on Sertraline he had put a belt around his neck and also, three days before his death his sister called the psychiatric unit and told a doctor that Stephen had “woke up” with a rope around his neck and wanted to come off all the medication immediately (he was advised to stay on the medication for another few weeks).
Stephen was a pioneer, he never in his life drank alcohol, smoked or took drugs. He was a very fit man and lead a healthy lifestyle. In retrospect, it is clear to us that Stephen suffered a severe reaction to the medication. Some of his symptoms included: an inability to sit still (pacing/walking); twitching/shaking; over sensitive to noises; feeling of mice crawling up his legs; insomnia; diarrhea; retching/vomiting, to name a few.
Please note, we are not interested in pursuing any civil action against the Trust. Stephen meant the world to us and we were unable to help him whilst he was with us. We truly believe had we listened to him and took him off the medication, he would be with us today. Ultimately, we are eager to have Stephen’s reaction to the antidepressants recognised, the true cause of death reflected in his death certificate and hopefully, in the future, other untimely deaths like Stephen’s, prevented.
If I were to provide you with all the information we have so far, are you able to provide us with your view on Stephen’s death? We would really appreciate your expert input.
Stephen turned out to an O’Neill who had been living in Northern Ireland. Whether he was Catholic or Protestant didn’t feature for me. Northern Irish politics can be complex with Terence O’Neill and Martin Smyth being part of the Unionist establishment and John Hume and Gerard Adams leading Nationalists.
Stephen’s medical records were sent to me along with a Root-Cause Analysis undertaken by the secondary health service he had been referred to when things began to go wrong. There were two things that were interesting about this. One was the family seemed to be the people putting akathisia on the map for the professionals. The second was the people from the service side involved in meeting the family seemed to be decent people.
There appeared to be a good case that treatment had played a part and some reason to believe that health service personnel were open to recognising this.
On October 2017, I submitted a straightforward report saying that but for the sertraline he had been given Stephen O’Neill would not have committed suicide but that no-one on the service side was to blame for this suicide – the key issues lay with the lack of access to clinical trial data which meant doctors were in the dark when they prescribed these drugs.
It was to take over 18 months for the inquest to be heard. It was originally scheduled for Belfast but it was transferred to Omagh – the site of the most terrible bombing during the Troubles. A place where the coroner still arrives to an inquest in an armour-plated vehicle and with an armed escort.
The coroner was Patrick McGurgan, one of three N Irish coroners, and the one whom the lawyer for the family suggested was probably the best person for the case.
The hearing lasted two days. Seven family members were in seats facing into the well of the Court on one side facing the coroner and his staff on a raised bench with the various lawyers for the coroner, the secondary services, the family doctor and the family in the middle. Experts and the press and other observers were on a bench on the opposite side facing across the lawyers and coroner to the family. The witness box, a tight uncomfortable affair was perched on the experts side in a place that made it difficult to look anyone in the face.
On the first day there were statements from the family and witness statements read into the record along with witness testimony from some of the secondary care medical personnel involved in the case during two brief admissions over a 6 week period and outpatient and community reviews. One of these offered the view that Dr Healy has an agenda. This line of questioning was blocked off and I’ve never found out what the agenda was – in part because of an extraordinary later development – it has proven essentially impossible for the family to get hold of a transcript of the hearings.