This continues the Spotlight on Suicides Series –
The photograph is of Patrick McGurgan – the coroner. Mr McGurgan appeared to be a decent man. He treated everyone with courtesy and appeared to be listening. His conclusions at the end of the inquest provoked a correspondence from me that will be posted later in this sequence in its entirety – there is nothing in this that impugns him.
The second day started on a strange note. Dr Brannigan, Stephen O’Neill’s family doctor, the first witness, and I arrived early. Several hours later nothing had begun and we were both still sitting on the bench for people other than the family, staring across at the family, with me at least wondering what was going on.
Stephen O’Neill had only taken two doses of the sertraline before stopping it and presenting to the hospital telling them he had had a very bad reaction to it. After a brief admission, nearly 6 weeks later he remained agitated – a series of drugs had been prescribed to him. Toward the end of this 6 weeks, a junior doctor working in the unit to which Stephen had been briefly admitted had been called to prescribe something to help Stephen who remained agitated. He prescribed Buspirone without seeing or interviewing Stephen. A few days later Stephen was dead.
Over the course of the 6 weeks, the hospital system and Dr Brannigan prescribed 4 drugs with the junior doctor in the hospital adding Buspirone (Buspar) into a mix that had included mirtazapine and quetiapine.
The addition of Buspirone led to a question as to whether it could have caused Stephen problems. The family’s lawyer called me that evening and asked whether there was any evidence it could. I prepared a Table of the hazards linked to 4 of the 5 different drugs Stephen had been given during this period and gave it to him to produce for the coroner the following morning.
This document shows that a large proportion of the reports on each of these drugs are for behavioural changes consistent with suicide induction. The rates of reports of problems triggered by each of these drugs is likely to be between 10-15% of the total of all reports for anxiety and 10-15% for depression and 10-15% for suicidality – perhaps 33-50% of all reports for each of these drugs. Reports of anxiety to FDA end up being coded under anxiety, stress, nervousness, restlessness etc with depression coded under depression, depressed mood, depressed state, mood disturbance – with no-one in FDA figuring it makes sense to add these up.
This sheet of paper led to a hold-up lasting hours as the coroner and his Q.C decided whether the evidence was admissible. They apparently consulted the FDA website and based on something they saw there about some reports being from patients, almost by definition without knowing what they were doing and without consulting me, they decided the evidence was not admissible.
The figures for Quetiapine bring out an important point. Stephen was given Quetiapine by his family doctor Dr Brannigan and by the secondary health services, as in the agitated state triggered by sertraline he was having difficulties in sleeping. He was told this would help. When later asked about how he was he made it clear that Quetiapine was not helping his sleep. His observations were ignored.
The Table however shows that his observations were almost certainly correct. While Quetiapine can be very sedative and many doctors give it in lieu of a sleeping pill, the FDA figures bring out that many doctors and others report to the companies marketing quetiapine (most FDA data comes from companies not patients) that some patients have just the opposite effect – Q interferes with their sleep.
Stephen was absolutely right when he reported this response but was not heeded. This was typical of what happened in his case from an initial catastrophic response to sertraline which he reported to the pharmacist who had dispensed it and later to anyone who would listen. But aside from a mention in the medical record that it was his view that his medication had caused him problems this view was essentially ignored.
Dr Brannigan took the stand once proceedings started. He appeared nervous to me. Mr McGurgan welcomed him to the stand. He made a point of thanking him for his excellent report. This was a model of clarity and he, Mr McGurgan, indicated an interest to use it if possible as a model of how a report should be done in training sessions he undertook with physicians and others.
It had always been my intention, as per my original report to avoid blaming any of the treating staff but these exchanges made it very clear that viewing Dr Brannigan as anything other than an excellent doctor was not an option.
Dr Brannigan did appear to be a decent man. His testimony took us through till lunchtime. It features in the next post.
I was called after lunch. A great deal my testimony covered details of Stephen’s case, as will become clear as these posts unfold.
Another chunk of testimony centred on explaining how decent doctors like Dr Brannigan and the doctors linked to the secondary care services could end up flailing around, not knowing what to do, and as a result resorting to throwing psychotropic drugs at the problem with their fingers crossed.
The explanation, a substantial proportion of which was delivered looking at Mr McGurgan straight in the eye hinged on the fact that the greatest concentration of Fake News on the planet centres on the drugs that family doctors, like Dr Brannigan, or hospital doctors, like the ones who had prescribed mirtazapine and buspirone, prescribe to you and me or our families and friends.
As I remember it, I more or less said to Mr McGurgan that he was not in a great position to establish the veracity of what I was telling his inquest, but that I had repeated the same message to Ministers of Health and the Chairman of NICE and others with none ever disputing what was being said. Given this it was rather easy to see how ordinary doctors fed a constant stream of hype about the benefits of treatment with the harms airbrushed out of existence would end up flailing around if a patient’s responses didn’t seem to fit the script.
I say – as I remember it – because I long ago expected to have a transcript of my testimony. This is available ordinarily for a small fee at the request of a family member or an expert but has been withheld in this case with no explanation offered for this withholding.
Coroners are in a tricky position. They are not medical experts and cannot readily come to a view that contradicts the medics who testify. Mr McGurgan had one doctor saying one thing and a number of others essentially saying they had done a good job.
However he did not have anyone contradicting the Fake News point. I didn’t expect he could solve a matter like this but I thought if I was in his position, I’d have written a conclusion (coroner’s verdicts are called conclusions) that bumped the matter up to a Minister of Health or First Minister saying “look I can’t come to a conclusion here without your involvement”.
One function of inquests is to advance the public health. There was another public health issues at stake here which was that Stephen O’Neill had died essentially kneeling rather than hanging. This is not uncommon in people plagued with drug induced thoughts of harming themselves who have no natural inclination to do so. They commonly put their head in a noose – experimenting as it were – not realising that quite minimal pressure from a rope on both sides of a neck can lead to a person losing consciousness and the noose tightening. This is very different to the person who attaches a noose and drops from a height. It’s something the public need to be warned about.
My testimony took up most of the afternoon of Thursday June 19th. The coroner was due to go on holiday that weekend. So the only day he could come to a conclusion was on the Friday. Conclusions are delivered in print but are then posted online.
A written conclusion was delivered before Mr McGurgan went on holiday but nothing has been put online as of the time of writing this post and no explanation has been offered as to why not in response to queries from the family or from me.
I wrote to Mr McGurgan, offering him the courtesy of letting him know that I would be writing to Ministers of Health and others about this case and would be embarking on a series of posts.
Next week – Spotlight on the Family Doctor.