Featured above is Landen, 11, (Prozac), Utah, sadly this is from the picture featured on his funeral program. On Prozac Landen got up early one morning, cooked breakfast for his family, then walked in another room & hung himself
Russian student being escorted from school after shooting
In Moscow today a high achieving student walked into his school with a rifle and gunned down a teacher and a police officer before his own father was able to persuade him to surrender the gun. The father first spoke with his son over the phone and then in person after he raced to the school. Now the boy will undergo a mental evaluation.
In the fall of 2007 a camera crew from a Russian news station came to my home in Des Moines, IA to interview me, film me giving a lecture to a group, and follow me around for a day. Their goal was to prevent what they saw here in America from happening in Russia by getting the truth about antidepressants and violence to the people of Russia.
The news crew even went to Israel to interview a young Russian woman who was one of the early cases I worked on. She and her Israeli fiancé had been attending school at the University of Utah when he first contacted me. She had started on birth control pills which caused her some very serious psychiatric side effects. So she was put on what was thought to be the “cure all” at the time, Prozac.
After being put on Prozac she became psychotic/manic so she was hospitalized at that point and they dropped her off Prozac to put her on Paxil! Of course that only made matters far worse and she became so suicidal that her fiancé could not allow her out of his sight even for a minute to go to the bathroom alone or she would attempt suicide again. So her fiancé, a brain chemist who felt he should have recognized this sooner, handcuffed her to him in order to save her life.
His plan worked and she filed suit against the drug makers and was given a gag order after settling like so many others who have sued and settled. But she lived because of her fiancé’s determination to save her any way possible even though he told me he was still frightened because she still had her teeth she could use as a weapon! 🙂
One interesting thing they told me is that even though they were atheists the only way they could describe her was as if she were possessed. She would even speak in a man’s voice.
They are doing very well. Both have graduated in their fields and have a family of their own now and they know to NEVER EVER take an antidepressant! She even traveled with me to Denver to testify to the Colorado congressmen looking into the cause of the shooting at Columbine.
So if you are thinking any country is safe and protected from this Serotonin Nightmare in which we all find ourselves, THINK AGAIN! Now we wait to see if this young man is among the 97% of school shooters on antidepressants or among the 3% who are not. Find a database of those shootings here: https://www.drugawareness.org/ssri-nightmares/school-shootings/
Additional Critical Information on School Shootings
Prophetic statement to me by a pharmacist on school shootings (1999):
“The symptoms I see in patients who abuse serotonergic drugs of any form…could aptly be described as the “Hitler syndrome” (over confidence in ones own policies or decisions, no fear of consequences, criminal behavior, death of people close to the abuser as the preferred method of solving problems in the abusers life, coldness and lack of humanity). I feel that in twenty years or less we will be confronted not with one Hitler but with thousands or millions… numbers so great that we will be forced to interact with their distorted thinking on a daily basis. (Littleton, CO., Riverton, KS., Jonesboro, AR., eventually little Hitlers in every town in America will grow up into BIG HITLERS) It is happening right now.
“The most insidious factor about long-term serotonin abuse is that it enhances the individuals persona to the point that they are able to manipulate others into their way of thinking just as Hitler did. This causes the distorted thinking, abnormal behavior, and loss of morality to spread like a contagion to otherwise normal people who have not even been exposed to the drugs. Those on the drugs are converted by the pharmacologic/physiologic processes into sociopathic demagogues.
“Do you have any comments on these thoughts, Ann? Please respond. Tell me we are not the only ones who see what is happening to our world!” (From Prozac: Panacea or Pandora? – Our Serotonin Nightmare)
Video of the only school shooter to ever speak out tells his story about what happened to him … “Why I Took A Gun To School” https://www.drugawareness.org/recentcasesblog/why-i-took-a-gun-to-school-1
Ann Blake Tracy, Executive Director,
International Coalition for Drug Awareness
www.drugawareness.org & http://ssristories.drugawareness.org
Author: ”Prozac: Panacea or Pandora? – Our Serotonin Nightmare – The Complete Truth of the Full Impact of Antidepressants Upon Us & Our World” & Withdrawal CD “Help! I Can’t Get Off My Antidepressant!”
WITHDRAWAL WARNING: In sharing this information about adverse reactions to antidepressants I always recommend that you also give reference to my CD on safe withdrawal, Help! I Can’t Get Off My Antidepressant!, so that we do not have more people dropping off these drugs too quickly – a move which I have warned from the beginning can be even more dangerous than staying on the drugs!
The FDA also now warns that any abrupt change in dose of an antidepressant can produce suicide, hostility or psychosis. These reactions can either come on very rapidly or even be delayed for months depending upon the adverse effects upon sleep patterns when the withdrawal is rapid! You can find the hour and a half long CD on safe and effective withdrawal helps here: http://store.drugawareness.org/
I want those who have created & peddled these deadly drugs to have to look into the faces of all who have died as a result of using antidepressants. I have been asking “How many more?” & “How long will we tolerate this?” for over 20 years. I have grown very weary of asking! All for greed . . . evidence proves it was nothing more than greed . . . no more benefit than a sugar pill . . . with suicide & homicide listed side effects . . . the approval was bribed! Our Serotonin Nightmare!
International Coalition for Drug Awareness
www.drugawareness.org & www.ssristories.drugawareness.org
Glaxo Is Testing Paxil on 7-Year-Olds Despite WellKnown Suicide Risks
By Jim Edwards | May 21, 2010
It was established years ago that Paxil carries a risk of suicide in children and teens, but GlaxoSmithKline (GSK) has for the last 18 months been conducting a study of the antidepressant in kids as young as seven — in Japan. It’s not clear why the company would want to draw more attention to its already controversial pill, but it appears as if GSK might be hoping to see a reduced suicide risk in a small population of users — a result the company could use to cast doubt on the Paxil-equals-teen-suicide meme that dominates discussion of the drug.
GSK didn’t immediately respond to a request for comment. A staffer on GSK’s trials hotline confirmed the study was ongoing, however. The drug carries a “black box” warning on its patient information sheet, warning doctors and consumers that the antidepressant is twice as likely to generate lethal thoughts than a placebo.
The trial criteria listed on ClinicalTrials.gov, however, provide an interesting lesson in how managers can carefully design drug trials designed to flatter their products — something good companies don’t do.
The primary aim of the study is not to find out why Paxil makes some children kill themselves. Rather, it’s yet another efficacy study, which the drug doesn’t need because it was approved years ago — we already know the drug works.
Paxil is being tested against a placebo, so the results won’t be very surprising — even terrible drugs work better than sugar pills.
To what degree Paxil triggers suicide is only a secondary aim of the study. If the results suggest a lower suicide risk, expect GSK to play them up. If they’re bad, expect the company to dismiss them in favor of the primary endpoint results.
About 130 children have been enrolled, according to ClinicalTrials.gov, which puts about 65 patients in each arm. That means the results won’t be too statistically robust — there only need to be two or three outlier results to skew the numbers by several percentage points.
The trial will wrap up in September.
Paragraph 14 reads: “The Petitioner had available as a
defense at trial and also as a competency issue the fact that he was
[intoxicated] from the ingestion of . . .[the] medically prescribed drugs[,
Moban and Prozac]. The Petitioner contends that this intoxication
constitutes a valid defense that was overlooked by defense counsel. The
prescribed medications were taken pursuant to medical advice and without [the
Petitioner’s] knowledge of [their] potentially intoxicating effects. . . .
Petitioner contends that due to the ingestion of the aforementioned prescription
drugs he was unexpectedly intoxicated to the point of unconsciousness, incapable
of controlling his actions, and thus not criminally responsible for his actions.
Because the Petitioner was unaware of the potential for his medications to
produce abnormal thought processes and behavior, and because [they were]
medically prescribed to him, the petitioner’s condition qualified as involuntary
intoxication. See T.C.A. § 39-11-503(c). As a result of the aforementioned
prescribed medication-induced physical disorder of the brain, the Petitioner was
(1) unable to exercise his customary moral judgment, (2) unable to control his
violent impulses, (3) unable to appreciate the consequences of his violent
actions, and (4) unable to appreciate right and wrong in regard to what he was
doing at the time of the
SILER v. STATE
JEFFERY T. SILER, JR.,
Court of Criminal Appeals
of Tennessee, at Knoxville.
Assigned on Briefs August 26,
Filed April 12, 2010.
Jeffery T. Siler, Pro Se, Only,
Robert E. Cooper, Jr., Attorney General and Reporter; and
Clark B. Thornton, Assistant Attorney General, for the Appellee, State of
Camille R. McMullen, J., delivered the opinion of the court,
in which Joseph M. Tipton, P.J., and D. Kelly Thomas, Jr., J.,
CAMILLE R. McMULLEN, JUDGE.
Petitioner, Jeffery T. Siler, Jr., appeals the Knox County Criminal Court’s
summary dismissal of his petition for post-conviction relief as untimely. On
appeal, the Petitioner contends that due process considerations toll the
one-year statute of limitations for post-conviction relief and entitle him to a
delayed appeal. Upon review, we reverse the judgment of the post-conviction
Prior to trial, the Petitioner pleaded guilty to the charge of
attempted especially aggravated robbery and received a sentence of eight years.
See State v. Jeffery T. Siler, No. E2000-01570-CCA-R3-CD, 2001 WL
387088, at *1 (Tenn. Crim. App., at Knoxville, Apr. 17, 2001). A Knox County
jury subsequently found the Petitioner guilty of the felony murder charge.
See id. He received a life sentence that was to be served
concurrently to his eight-year sentence for the attempted especially aggravated
robbery conviction. See id. The Petitioner’s convictions were
affirmed on direct appeal, and the Petitioner did not file an application for
permission to appeal to the Tennessee Supreme Court pursuant to Rule 11 of the
Tennessee Rules of Appellate Procedure. See id.
13, 2009, the Petitioner filed a petition for post-conviction relief, claiming,
among other things, that: (1) his conviction was based on a coerced confession;
(2) his conviction was based on a violation of the privilege of
self-incrimination; (3) he received ineffective assistance of counsel at trial;
(4) he had newly discovered evidence; (5) his attorney failed to appeal to the
Tennessee Supreme Court after his convictions were affirmed on direct appeal;
(6) his attorney failed to withdraw following the direct appeal; (7) he had a
right to a delayed appeal because his attorney failed to appeal his case to the
Tennessee Supreme Court after his convictions were affirmed on direct appeal and
because his attorney failed to withdraw after the direct appeal; (8) he received
ineffective assistance of counsel at his transfer hearing; (9) his attorney was
ineffective for failing to argue he was incompetent because of involuntary
intoxication from prescribed medicatons and for failing to assert the defense of
involuntary intoxication; (10) his attorney was ineffective for failing to
investigate his psychiatric history and for failing to include this history in a
motion to suppress his pretrial statements; (11) his attorney was ineffective
for failing to hire an expert to support the defense of involuntary intoxication
from prescribed medications which established his actual innocence; (12) his
attorney was ineffective for failing to argue the Petitioner was insane at the
time of the homicide and for failing to hire an expert to support the defense of
insanity; (13) the grand jury that returned the indictment against him was
unconstitutionally selected because it did not reflect a cross-section of the
community and his attorney was ineffective for failing to raise this issue; (14)
the State committed prosecutorial misconduct by making inflammatory comments
about the Petitioner, the evidence, and the crime, and by implying that the
Petitioner would commit other crimes if the jury did not convict him; and (15)
the trial court erred by allowing “irrelevant, inadmissible, and false evidence”
to be presented to the jury, by failing to charge the jury on all applicable
defenses, and by failing to charge the jury on all lesser-included offenses. On
February 20, 2009, the post-conviction court summarily dismissed the petition as
untimely. The post-conviction court’s order did not address whether due process
required tolling of the statute of limitations period. On March 2, 2009, the
Petitioner filed a notice of appeal.
In the opinion on direct appeal,
this court provided a summary of the underlying facts in this case:
- On February 19, 1998, the fifteen-year-old defendant and fifteen-year-old
Lavon Davis were riding with Jason Copley. Davis stated that he was “looking
for a lick,” meaning someone to rob. Upon seeing fifty-six-year-old Tommy
Haworth, the victim, walking down the street, they decided to rob him. The
defendant agreed to take Davis’ pistol, and Davis and the defendant exited the
vehicle and followed the victim to his residence. There, the defendant
confronted the victim and asked him for money. The victim replied that he had
none. The defendant then cocked the pistol, and it fired. The victim was hit
in the face with the bullet and died as a result of this gunshot wound.
- The defendant and Davis fled the scene, and the defendant threw the empty
shell casing into a storm drain. Copley, who had remained in the vehicle,
stayed at the scene and told someone to call 911.
- The defendant and Davis were subsequently arrested, and the defendant
confessed his involvement in the offense. In his statement the defendant
contended the gun went off accidentally during the attempted robbery, and he
did not intend to shoot the victim. An analysis of the shell casing found in
the storm drain and the projectile recovered in the victim’s toboggan revealed
they were fired from the pistol recovered from Davis’ coat pocket. The
defendant’s fingerprints were also found on the door of the victim’s
- The defendant was transferred from juvenile court to the Criminal Court
for Knox County and indicted in Count 1 for first degree murder during the
perpetration of an attempted especially aggravated robbery and in Count 2 for
attempted especially aggravated robbery. On the morning of trial, the
defendant entered a guilty plea to attempted especially aggravated robbery,
and the case was tried before a jury on the felony murder charge. The jury
found the defendant guilty of felony murder. The defendant was sentenced to
concurrent sentences of life for felony murder and eight years for attempted
especially aggravated robbery.
Id. at *1 (internal footnote
On appeal, the Petitioner argues that the post-conviction court
erred in dismissing his petition for post-conviction relief as untimely. He also
contends that due process considerations should toll the post-conviction statute
in light of his counsel’s failure to appeal his case to the Tennessee Supreme
Court after his convictions were affirmed on direct appeal, his counsel’s
failure to withdraw as counsel pursuant to Tennessee Supreme Court Rule 14, and
his counsel’s failure to argue that he was incompetent because of involuntary
intoxication and failure to assert the defense of involuntary intoxication at
trial. As explanation for his untimely filing, the Petitioner claims in his
appellate brief that his “multiple mental health diagnoses” including “mental
retardation” prevented him from determining how much time it would take for the
Tennessee Supreme Court to grant or deny counsel’s promised application for
permission to appeal. See Tenn. R. App. P. 11. Finally, the Petitioner argues
that he should be given a delayed appeal to the Tennessee Supreme Court because
of these due process violations. See Tenn. Sup. Ct. R. 28, § 9(D)(1)(b). In
response, the State argues that the Petitioner’s claims do not qualify as
exceptions to the statute of limitations, that the post-conviction court
properly dismissed his petition as untimely, and that he is not entitled to a
delayed appeal based on due process concerns.
Regarding counsel’s failure
to appeal his case following the direct appeal, the Petitioner cites to
counsel’s April 19, 2001 letter to him, wherein counsel stated:
- Your appeal was denied by the Court of Criminal Appeals. I shall ask for
permission to appeal to the Tennessee Supreme Court, unless you instruct me
otherwise within the next ten (10) days. A copy of the Court’s opinion is
- If I do not hear from you within the next ten (10) days, I shall prepare a
Request for Permission to Appeal to the Supreme Court of Tennessee. While I do
not think permission to appeal will be granted, I believe it is obviously in
your best interest for me to ask on your behalf. Thank you for the opportunity
to represent you in this matter.
The Petitioner also cites to
counsel’s November 4, 2008 letter to the Board of Professional Responsibility,
wherein counsel stated: “The Court of Criminal Appeals denied Mr. Siler’s
appeal, and he did not contact me within thirty (30) days, orally or in writing,
to appeal to the Supreme Court.”
Regarding counsel’s failure to withdraw
pursuant to Tennessee Supreme Court Rule 14, the Petitioner cites to the
response he received from Becky Doyal, the Deputy Clerk of the Courts of the
State of Tennessee, wherein she stated:
- Your question: “Did [counsel] file a motion to withdraw on your behalf[.”]
If you are asking if [counsel] filed a motion to withdraw as your attorney,
the answer is no. If you are asking if [counsel] filed a motion to withdraw
the appeal, the answer is no.
The Petitioner included copies of
counsel’s April 19, 2001 letter, counsel’s November 4, 2008 letter to the Board
of Professional Responsibility, and the response from the Deputy Clerk of the
Courts of the State of Tennessee as exhibits to his petition for post-conviction
Finally, regarding counsel’s failure to assert competency or
defense arguments based on involuntary intoxication, the Petitioner argues:
- The Petitioner had available as a defense at trial and also as a
competency issue the fact that he was [intoxicated] from the ingestion of . .
.[the] medically prescribed drugs[, Moban and Prozac]. The Petitioner contends
that this intoxication constitutes a valid defense that was overlooked by
defense counsel. The prescribed medications were taken pursuant to medical
advice and without [the Petitioner’s] knowledge of [their] potentially
intoxicating effects. . . . Petitioner contends that due to the ingestion of
the aforementioned prescription drugs he was unexpectedly intoxicated to the
point of unconsciousness, incapable of controlling his actions, and thus not
criminally responsible for his actions. Because the Petitioner was unaware of
the potential for his medications to produce abnormal thought processes and
behavior, and because [they were] medically prescribed to him, the
petitioner’s condition qualified as involuntary intoxication. See T.C.A. §
39-11-503(c). As a result of the aforementioned prescribed medication-induced
physical disorder of the brain, the Petitioner was (1) unable to exercise his
customary moral judgment, (2) unable to control his violent impulses, (3)
unable to appreciate the consequences of his violent actions, and (4) unable
to appreciate right and wrong in regard to what he was doing at the time of
“[A] person in custody under a sentence of a
court of this state must petition for post-conviction relief within one (1) year
of the date of the final action of the highest state appellate court to which an
appeal is taken or, if no appeal is taken, within one (1) year of the date on
which the judgment became final. . .” T.C.A. § 40-30-102(a) (2006). The statute
explicitly states, “The statute of limitations shall not be tolled for any
reason, including any tolling or saving provision otherwise available at law or
equity.” Id. It further stresses that “[t]ime is of the essence of the right to
file a petition for post-conviction relief or motion to reopen established by
this chapter, and the one-year limitations period is an element of the right to
file the action and is a condition upon its exercise.” Id. In the event that a
petitioner files a petition for post-conviction relief outside the one-year
statute of limitations, the trial court is required to summarily dismiss the
petition. See id. § 40-30-106(b) (2006). Similarly, “[i]f, on reviewing the
petition, the response, files, and records, the court determines conclusively
that the petitioner is entitled to no relief, the court shall dismiss the
petition.” Id. § 40-30-109(a) (2006). Furthermore, “[i]f and when a petition is
competently drafted and all pleadings, files and records of the case
conclusively show that the petitioner is entitled to no relief the court may
properly dismiss the petition without the appointment of counsel or conducting a
hearing.” Martucci v. State, 872 S.W.2d 947, 949 (Tenn. Crim. App. 1993) (citing
T.C.A. § 40-30-109; Stokely v. State, 470 S.W.2d 37, 39 (Tenn. Crim. App.
Tennessee Code Annotated section 40-30-102(b) (2006) sets out
three exceptions to the statute of limitations for petitions for post-conviction
- No court shall have jurisdiction to consider a petition filed after the
expiration of the limitations period unless:
- (1) The claim in the petition is based upon a final ruling of an appellate
court establishing a constitutional right that was not recognized as existing
at the time of trial, if retrospective application of that right is required.
The petition must be filed within one (1) year of the ruling of the highest
state appellate court or the United States supreme court establishing a
constitutional right that was not recognized as existing at the time of trial;
- (2) The claim in the petition is based upon new scientific evidence
establishing that the petitioner is actually innocent of the offense or
offenses for which the petitioner was convicted; or
- (3) The claim asserted in the petition seeks relief from a sentence that
was enhanced because of a previous conviction and the conviction in the case
in which the claim is asserted was not a guilty plea with an agreed sentence,
and the previous conviction has subsequently been held to be invalid, in which
case the petition must be filed within one (1) year of the finality of the
ruling holding the previous conviction to be
Additionally, due process concerns may toll the
statute of limitations for post-conviction relief. The Tennessee Supreme Court
- [B]efore a state may terminate a claim for failure to comply with
procedural requirements such as statutes of limitations, due process requires
that potential litigants be provided an opportunity for the presentation of
claims at a meaningful time and in a meaningful manner.
v. State, 845 S.W.2d 204, 208 (Tenn. 1992) (citing Logan v. Zimmerman Brush Co.,
455 U.S. 422, 437, 102 S. Ct. 1148, 1158-59 (1982)).
Here, the Petitioner
was required to file his petition for post-conviction relief within one year of
April 17, 2001, the date that the Tennessee Court of Criminal Appeals affirmed
his convictions on direct appeal, which was the final action of the highest
state appellate court to which an appeal was taken in his case. See T.C.A. §
40-30-102(a) (2006). The Petitioner does not list any ground that would make him
eligible for the exceptions to the one-year statute of limitations. See id. §
40-30-102(b) (2006). However, regarding counsel’s failure to appeal to the
Tennessee Supreme Court after his direct appeal and counsel’s failure to
withdraw as counsel, he relies on Williams v. State, 44 S.W.3d 464, 468 (Tenn.
2001), for the proposition that due process considerations should toll the
one-year statute of limitations for filing his petition for post-conviction
relief. In Williams, the Tennessee Supreme Court stressed that in limited
circumstances an attorney’s misrepresentation to a petitioner could result in a
tolling of the statute of limitations for due process concerns:
- [W]e are not holding that a petitioner may be excused from filing an
untimely post-conviction petition as a result of counsel’s negligence.
Instead, the focus here is . . . upon trial and appellate counsel’s alleged
misrepresentation in failing to . . . notify the petitioner that no
application for permission to appeal would be filed in [the Tennessee Supreme]
Williams, 44 S.W.3d. at 468 n.7. In Craig Robert Nunn,
this court agreed that “[t]he Williams decision is not intended to require a
hearing on due process concerns every time a petitioner alleges that the
untimeliness of his petition is due to his trial or appellate counsel’s
negligence.” Craig Robert Nunn v. State, No. M2005-01404-CCA-R3-PC, 2006 WL
680900, at *5 (Tenn. Crim. App., at Nashville, Mar. 17, 2006) (citing Bronzo
Gosnell, Jr. v. State, No. E2004-02654-CCA-R3-PC, 2005 WL 1996629, at *4 (Tenn.
Crim. App., at Knoxville, Aug. 19, 2005), perm. to appeal denied (Tenn. Dec. 19,
2005)). However, this court explained that the facts in the Williams case
necessitated an evidentiary hearing:
- In Williams, the inmate/petitioner averred that he believed trial counsel
was continuing to represent him through the appeals process. The court
remanded for an evidentiary hearing on grounds that the inmate/petitioner
might “have been denied the opportunity to challenge his conviction in a
timely manner through no fault of his own but because of the possible
misrepresentation of counsel.”
Barry N. Waddell v. State, No.
M2001-00096-CCA-R3-PC, 2001 WL 1246393, at *3 (Tenn. Crim. App., Nashville, Oct.
17, 2001) (quoting Williams, 44 S.W.3d at 468) (emphasis added)), perm. to
appeal denied (Tenn. Apr. 8, 2002). Ultimately, the court in Williams remanded
the appellee’s case to the trial court for an evidentiary hearing to determine:
- (1) whether due process tolled the statute of limitations so as to give
the appellee a reasonable opportunity after the expiration of the limitations
period to present his claim in a meaningful time and manner; and (2) if so,
whether the appellee’s filing of the post-conviction petition . . . was within
the reasonable opportunity afforded by the due process tolling. Williams, 44
S.W.3d. at 471. The Williams court then held that if the trial court
determined that the statute of limitations should be tolled and that the
appellee had filed his petition for post-conviction relief within the
“reasonable opportunity afforded by the due process tolling” then the trial
court would have “jurisdiction to determine whether Williams was deprived of
his right to request pro se Supreme Court review under Rule 11 of the
Tennessee Rules of Appellate Procedure.” Id. at 472 (citing Tenn. Sup. Ct. R.
28, § 9(D)).
Although the Petitioner does not specifically cite
State v. Nix, 40 S.W.3d 459 (Tenn. 2001), we think this case is also
particularly relevant, given the Petitioner’s claim in his appellate brief that
his mental conditions prevented him from determining how much time it would take
for the Tennessee Supreme Court to grant or deny counsel’s promised application
for permission to appeal. Prior to Nix, the Tennessee Supreme Court, following
the holding in Watkins v. State, 903 S.W.2d 302, 307 (Tenn. 1995), concluded
that “mental incompetency, if established, tolled the statute of limitations.”
Seals v. State, 23 S.W.3d, 272, 279 (Tenn. 2000). The court further held that
the statute of limitations for post-conviction relief should not deny a
Petitioner the right to raise a claim in a meaningful time and manner:
- [W]e conclude that while the one-year statute of limitations set forth in
Tenn. Code Ann. § 40-30-202(a) does not violate due process on its face,
application of the statute must not deny a petitioner a reasonable opportunity
to raise a claim in a meaningful time and manner. Thus, a petitioner who is
mentally incompetent is denied an opportunity to raise a claim in a meaningful
manner unless the statute of limitations is tolled during the period of mental
Id. Less than a year later, the Tennessee Supreme
Court held that the Watkins and Seals cases did not specify the standard of
mental incompetence that a petitioner must satisfy in order for due process
concerns to toll the statute of limitations for post-conviction relief. Nix, 40
S.W.3d at 463. Ultimately, the court held:
- We emphasize that to make a prima facie showing of incompetence requiring
tolling of the limitations period, a post-conviction petition must include
specific factual allegations that demonstrate the petitioner’s inability to
manage his personal affairs or understand his legal rights and liabilities.
Unsupported, conclusory, or general allegations of mental illness will not be
sufficient to require tolling and prevent summary dismissal under Tenn. Code
Ann. § 40-30-206(b) & (f).
Id. at 464-65.
the Petitioner contends that counsel violated his due process rights by failing
to appeal his case to the Tennessee Supreme Court after his convictions were
affirmed on direct appeal, by failing to withdraw as counsel pursuant to
Tennessee Supreme Court Rule 14, and by failing to argue that he was incompetent
because of involuntary intoxication and failing to assert involuntary
intoxication as a defense at trial. We recognize that the petition for
post-conviction relief was not filed until February 13, 2009, nearly seven years
after the expiration of the one-year statute of limitations. In addition, based
on the record, the Petitioner’s February 13, 2009 petition appears to be the
first time he has argued that due process concerns should toll the one-year
statute of limitations. See Richard A. Emmitt v. State, No.
M2004-00564-CCA-R3-PC, 2005 WL 639133, at *6 (Tenn. Crim. App., Nashville, Mar.
16, 2005) (concluding that the trial court’s dismissal was proper where the
Petitioner waited eighteen years after his convictions became final before
filing a petition for post-conviction relief and before requesting a delayed
appeal to the Tennessee Supreme Court), perm. to appeal denied (Tenn. June 27,
2005). However, as explanation for his lengthy delay in filing his
post-conviction, the Petitioner argues in his appellate brief but not in his
petition for post-conviction relief that his “multiple mental health diagnoses”
including “mental retardation” prevented him from determining how much time it
would take for the Tennessee Supreme Court to grant or deny counsel’s promised
application for permission to appeal. The Petitioner further asserts, on appeal
and in his post-conviction petition, that he lived in a psychiatric institution
nearly his entire childhood and that he was receiving Social Security benefits
for a mental disability and was taking the prescriptions Moban and Prozac for
schizophrenia at the time of the homicide in this case. He attached medical
records documenting his mental conditions from his early childhood to his
petition; however, there are no records showing his condition after
Upon our review of the record, we conclude that the
post-conviction court erred in dismissing the petition without conducting a
hearing to make determinations as outlined in Williams. See Eric Wright v.
State, No. W2001-00386-CCA-R3-PC, 2001 WL 1690194, at *2 (Tenn.Crim.App., at
Jackson, Dec. 17, 2001). Here, the Petitioner attached a letter from counsel as
proof of counsel’s intent to file for a Rule 11 appeal as well as a letter from
the court clerk as proof of counsel’s failure to properly withdraw from his
case. Before dismissing the petition as untimely, Williams required the trial
court to conduct a hearing to determine if “in fact, [the petitioner] [was]
misled to believe that counsel was continuing the appeals process, thereby
requiring the tolling of the limitations period.” Williams, 44 S.W.3d at 471;
see also Shelvy Baker v. State, 2008 WL 2648957, at 2 (Tenn.Crim.App. 2008)
(concluding that petitioner’s allegations that counsel “(1) failed to notify the
Petitioner that counsel did not intend to file a Rule 11 application for
permission to appeal; (2) failed to formally withdraw as the attorney of record
or otherwise failed to inform the Petitioner of counsel’s withdraw; and (3)
counsel assured `the Petitioner that he would take the case all the way to the
Tennessee Supreme Court'” required a Williams based evidentiary
Accordingly, we are constrained to reverse the post-conviction
court’s summary dismissal of the petition and remand for an evidentiary hearing.
On remand, the post-conviction court is required to determine
- (1) whether due process tolled the statute of limitations so as to give
the [Petitioner] a reasonable opportunity after the expiration of the
limitations period to present his claim in a meaningful time and manner; and
(2) if so, whether the [Petitioner’s] filing of the post-conviction petition
in [February 2009] was within the reasonable opportunity afforded by the due
Williams, 44 S.W.3d at 471. In addition, on
remand, the trial court should consider the Petitioner’s claims regarding his
mental condition against the standard for mental competency established in State
v. Nix, 40 S.W.3d 459, 464 (Tenn. 2001).
We reverse the post-conviction
court’s summary dismissal of the Petitioner’s petition for post-conviction
relief and remand for further proceedings consistent with this
NOTE FROM Ann Blake-Tracy:
child on Zoloft has told me of both thoughts and plans to kill that they
developed on Zoloft. Eric Harris, the lead shooter at Columbine, had those
thoughts within three weeks on Zoloft and found them to be so disturbing to him
that he reported it and they took him off Zoloft and put him on another
antidepressant. [What is the definition of insanity? Doing the same thing and
expecting a different result – the other antidepressant, Luvox, ended up
producing thoughts of killing intense enough to result in the largest school
shooting the world had ever witnessed at that point.] I even had a case of a 5
year old boy in Southern Utah who had such intense feelings of homicide that he
told his family he was going to have the police come and kill them
like this of children killing while under the influence of
Curtis spoke to police when he was out of the room. She told them the boy was in
counseling, that he had been fighting at school, that he had been prescribed
Zoloft and a mood stabilizing medicine. Then, Curtis provided a tearful account
of what he said happened.”
Infant‘s mother testifies as Tampa boy stands trial in Georgia
Zayas, Times Staff Writer
In Print: Thursday,
December 10, 2009
MARIETTA, Ga. On the Fourth of July, Brittiany
Young returned to her car in a Target parking lot and put it in reverse. That’s
when she noticed the swollen mouth of her 5–week–old daughter,
Young put the car in park and turned to her cousin, a 12–year–old
Tampa boy she had left alone with the baby.
“What did you do?” she asked.
“What did you do to her?”
The mother testified Wednesday morning in a
Cobb County, Ga., courtroom, where the Tampa boy faces charges of felony murder
and cruelty to children. He has pleaded not guilty. Juvenile Court Judge A.
Gregory Poole will decide the case without a jury.
The unidentified boy
a court order keeps his name secret was visiting relatives July 4
outside Atlanta when his cousin stopped at the Target to pick up food for a
picnic. According to court testimony, the 22-year–old mother left the keys in
the ignition and the air conditioning on as she shopped at the store for 18
minutes. When Young returned, the boy was playing on his cell phone in the back
seat. The radio was turned louder. And the infant was not responsive.
baby girl was taken off life support the next day. A medical examiner found
multiple skull fractures and ruled the cause of death blunt force trauma to the
The boy has remained in Georgia since July, first locked up in a
juvenile detention center, then transferred to a secure group
Authorities said nothing specific about how they think the baby
died until Wednesday morning.
“Something so horrific happened that
pictures don’t do it justice,” prosecutor Eleanor Odom said in her opening
statement. “That child’s head was bashed in.”
The boy‘s attorney, Derek
Wright, had another word to describe the prosecution’s case:
He said prosecutors would not be able to provide a scenario
showing exactly what act of violence befell the baby no weapon, no points
of impact in the car.
By Wednesday night, they still had not.
In the courtroom, the sixth-grader wore a gold suit like the one
he wore to his elementary school graduation.
When his mother, his father
and his great-aunt cried when the baby’s mother cried he remained
But emergency responders who first arrived at the scene
testified that they saw him pacing and sobbing. They noted a different, more
calm reaction from the mother. Paramedic Pierce Summers saw her later at the
“For someone that had had a child in that circumstance, it was
surprising,” he said, “like she was kind of lost in a fog.”
described what her baby looked like in the car: eyes swollen and hard to the
touch; blood on her mouth or nose; limp.
On July 5, the baby girl was
deemed brain dead and taken off life support. The prosecutor asked the mother,
“Were you there when Millan died?”
She paused to wipe tears. Then, she
After the judge ordered a break and the infant‘s mother left
the stand, the boy burst into tears. He stood up, turned around and looked at
his mother, who stood up from a bench and kissed his forehead.
For much of the day and into the night, the prosecution focused on
three videotaped interviews the boy gave detectives.
The third was the
subject of an hourslong debate. The defense fought hard to have it suppressed,
saying the boy was forced to give incriminating statements.
first, the boy told detectives what he told the baby’s mother: The baby began to
cry, so he tried to give her a pacifier. She spit it out, so he tried to give
her a bottle of water. She kept screaming, and was scratching her face. He
turned the radio loud, and it appeared she went to sleep.
The boy‘s story
didn’t stray far from his original account in his second interview, which he
gave the day after the baby was pronounced dead.
“If you accidentally
hurt Millan, would you tell us?” the detective asked.
“Yes,” the boy
said. “I didn’t accidentally hurt her. . . . I don’t want to hurt a
But a couple of hours after he gave that interview while
their entire family was gathered at the baby’s mother’s house the boy‘s
mother, Camille Curtis, brought him back to speak with police. This time, she
was crying. She said he had told her something.
“It was just an
accident,” Curtis said. “He said he was scared. I asked him. He told me. He
thought I was going to be mad.”
Detectives asked the boy if he wanted to
talk. The boy shook his head.
While the boy continued to refuse, Curtis
spoke to police when he was out of the room. She told them the boy was in
counseling, that he had been fighting at school, that he had been prescribed
Zoloft and a mood stabilizing medicine. Then, Curtis provided a tearful account
of what he said happened.
She said he told her the baby started choking
when he tried to give her the bottle. He lifted her to his chest to burp her,
and she fell out of his hands.
The boy told the baby’s mother he was
sorry, Curtis said.
At that point in the videotape, the police told her
that this story didn’t match the injuries. The video shows her pleading with her
son to tell the police the truth, that he wouldn’t be allowed to go home until
He tells her he wiped the baby’s blood with a blanket, and that
he accidentally hit her with his elbow while trying to pick her up off the
Just before midnight on the videotape, when it appeared the boy
was about to talk, the judge stopped the tape.
“I find this to be
inherently unfair,” the judge said. “This child is so scared . . . literally in
a corner. His mother is pressuring him. How many times does the kid say he
doesn’t want to talk?”
With that, the judge struck the entire third
interview from the record. None of it will factor into the decision he will make
The trial continues today.
Alexandra Zayas can be
reached at firstname.lastname@example.org or (813) 310-2081.
[Last modified: Dec
09, 2009 11:29 PM]
Verdict: Guilty, but not of murder
Dressed in a shirt and tie, the skinny, dimpled boy stayed calm as the
judge delivered his verdict: “I find beyond a reasonable doubt that Millan
suffered major trauma during the 18 minutes the juvenile was alone with the
baby. … I find that the juvenile caused the injuries and that the baby later
died as a result of the trauma.
“Now, what do I think happened? This child was left alone with the baby.
I don’t know that should have happened, but it did …
“Millan, a child he really didn’t know, started crying, and it got louder
“He didn’t know what to do. I think he was scared. He tried using the
pacifier to make this baby stop crying. It didn’t work. What did he do
“He got out the bottle of water … He gives it to the baby. The baby won’t
be quiet. Turns up the radio so he won’t have to hear this baby crying. That
didn’t work. He might have even turned it up again. Well, the pink pacifier
didn’t work. Let’s use the purple pacifier …
“This juvenile was trying to get the baby to quit crying. … He was
scared, and he didn’t know what to do. … I wouldn’t expect him to know what to
“I find that in order to get the baby to be quiet, using his own means as
a 12–year–old, that he committed batteries, plural, against this baby
“Did this child mean that his actions would kill Millan? No …
“Technically, I think I can find possibly if I wanted to go further, some
type of an involuntary manslaughter. In my mind, I’ve still got to place this
child with some expectation, some appreciation for the horrific damage that it
has done, and I find nothing along those lines.
“Did he do wrong? Oh yeah, he did. I wish it hadn’t happened, but it
Did a drug lead to killing?
Shane Clancy’s mother and stepfather alleged on ‘The Late Late Show’ that
antidepressants caused him to stab three people, and then himself. However, no
medical research has ever linked these drugs to homicide
ON AUGUST 16th, 22-year-old Sebastian Creane from Bray, Co Wicklow, was
fatally stabbed by Shane Clancy, who also injured Sebastian’s brother Dylan and
Jennifer Hannigan, Clancy’s ex-girlfriend. On October 2nd, Shane Clancy’s mother
and stepfather, also from Bray, appeared on The Late Late Show to
argue that in their view Shane’s behaviour was so uncharacteristic that it could
only be explained by the fact that he had been taking antidepressants.
“The conversation gave the impression that antidepressants increase the risk
for homicide. There is absolutely no link between taking antidepressants and
homicidal behaviour,” says Dr Jogin Thakore, clinical director of psychiatry in
the HSE’s Dublin North Central district.
Dr Justin Brophy, a consultant psychiatrist in Co Wicklow agrees, adding: “I
would be extremely concerned that following The Late Late Show ,
people who have been prescribed antidepressants would stop taking them, and that
people who need to take them in order to function in their lives will feel
stigmatised, and may even hide the fact that they are taking them. The stakes
are very high here because people’s lives and people’s health will be seriously
compromised and endangered by misleading and imbalanced advice.”
After hundreds of scientific studies and independent evaluation by the US
Food and Drug Administration (FDA), the EU and the Irish Medicines Board (IMB),
antidepressants have probably come under more scrutiny than most drugs on the
market. The worst you can say of them is that in the under-25 age group they are
linked to increased “suicidal ideation” – as in thoughts of suicide – but they
have not yet been shown to cause suicides.
Yet there are many people who refuse to accept the evidence. Just type
“antidepressants violence” into your web browser, and you will find hundreds of
sites with anecdotal claims that troubled adolescents (keep in mind that the
mind is adolescent until the age of 25 or even 30) became violent after taking
The College of Psychiatrists in Ireland refused an invitation to participate
in the The Late Late Show on October 2nd.
“Making antidepressants the focus of this tragic situation was a serious
hijacking of two families’ grief and of the facts, while the facts of the case
have yet to be established. We thought it was unethical to parade the issue of
antidepressants in front of a bereaved family who had been hijacked for the sake
of the argument. We also had misgivings that another brave family was not
represented,” says Dr Brophy.
Dr Brophy believes the “sensationalistic” misinformation peddled by media and
special interest groups about antidepressants amounts to “scientific bullying”.
He says, “A small group of people with a particular agenda aim to completely
decimate the facts, manipulating methodologies for their own ends. The legal
industry is also heavily invested. Those interests are not declared and
expressed in websites and sensationalist media reports. It represents a form of
Dr Michael Corry stated on The Late Late Show that he had seen
Shane Clancy’s parents twice as their psychiatrist and was in the green room
with them beforehand, he then said of antidepressants that: “The side effects
which are recognised can tip somebody into suicidal behaviour and homicidal
behaviour. This is well documented.” Two other doctors, both GPs, were also in
the studio audience and did not say on air that there is no scientific proof of
Dr Corry’s view.
When asked whether the item was intended by Clancy’s parents to be a warning
on antidepressants, based on their own beliefs, RTÉ responded that: “As a
policy, RTÉ Television doesn’t discuss the motivations of guests in
participating in any of our shows – that is for them to elucidate. These
discussions are private to the parties involved. However, we can clarify that Ms
Fennell’s concerns about the possible effects antidepressant drugs had on her
son had already been publicly aired – in a letter to the Gerry Ryan
Show (Wednesday 16 September).
“We felt that the Clancy’s beliefs and comments would lead to a wider
discussion on the approaches to treating depression in Ireland. The item
included mental health experts in the audience who could contribute expert
opinion on antidepressants in particular and mental health care provision in
general. Two expert opinions were offered which differed from Leonie Fennell and
Tony Donnelly’s position and one supported their thesis. Advice was offered to
any viewers currently on antidepressant medication to seek medical advice before
changing any aspect of their treatment. The Aware helpline number was also put
up on screen at the conclusion of the item during The Late Late
Show on Friday night, for any viewers affected by the discussion.”
IN IRELAND , a reliable source of information is the
IMB, which has the role of evaluating every drug that companies seek to put on
the market here. Evidence presented by the pharmaceutical industry is only one
of the research sources reviewed by the board. Epidemiological studies and
“surveillance” – alerts from doctors prescribing the drug – are also taken into
account. The IMB doesn’t approve anything that the EU and the FDA haven’t
thoroughly investigated first, and it then reviews these investigations with an
In 2006, the IMB reviewed all the current evidence and wrote a warning that
comes on a leaflet inside antidepressant prescription boxes. It states: “If you
are depressed and/or have anxiety disorders you can sometimes have thoughts of
harming or killing yourself. These may be increased when first starting
antidepressants, since these medicines all take time to work, usually about two
weeks but sometimes longer.” It adds that “if you are a young adult, information
from clinical trials has shown an increased risk of suicidal behaviour in adults
aged less than 25 years with psychiatric conditions who are treated with an
The warning refers to suicidal behavour, not actual suicides. In August, the
British Medical Journal published a study showing that the risk of
suicide in under-25s on antidepressants was about one in 12,000 – but there was
absolutely no risk of homicidal behaviour. It hasn’t turned up in a single
Some people believe doctors and the pharmaceutical companies work
hand-in-glove to suppress the evidence. Says Dr Brophy: “If there was any
implication of concealment of the truth, the IMB would know it. The facts are
very open and accessible. No one is trying to conceal anything. . . . To imply
[we] are beholden to the pharmaceutical industry is a misrepresentation. We
don’t prescribe based on any information from the pharmaceutical industry – we
get it from the IMB.”
AN ESTIMATED 400,000 people in Ireland suffer with
depression. The WHO has estimated that by 2030, depression will overtake heart
disease as the illness causing the most distress both in terms of individual
suffering and human productivity. Stigmatising depression, by linking its
pharmacological treatment to violent behaviour, can only prevent people from
seeking help, Dr Thakore warns.
How many Irish people take antidepressants? It’s a difficult figure to come
by. More than 1.1 million prescriptions annually for new-generation
antidepressants are paid for by the general medical scheme (GMS), and another
100,000 under the direct payment (DP) scheme.
Dr Harry Barry, a GP and cognitive behavioural therapist, who was in The
Late Late Show audience that night, says prescription drugs are an
important part, but not all, of the solution for depression. Teenagers,
especially, need someone to listen to them with empathy so that they can tell
the truth about how they feel. Many young people with depression, he says, are
fearful of their parents and friends knowing that they are not the wonderful,
sociable person they think they are; this fear of letting people down can lead
Lifestyle changes are also important – avoiding alcohol and illegal drugs,
improving diet and exercising. The focus should not be on antidepressants, but
on the services, Dr Barry believes. According to a recent report, only 12 per
cent of adolescents with mental health problems have access to a specialist
This article appears in the print edition of the
Throm is found guilty in death of girlfriend
By Steve Sharp
Daily Times staff
A 42-year-old Palmyra man was found guilty this morning of first-degree homicide and a charge of hiding a corpse by a Jefferson County judge.
Jefferson Co., Wisconsin vs. David Throm (Criminal Trial)
Throm is found guilty in death of girlfriend
By Steve Sharp
Daily Times staff
A 42-year-old Palmyra man was found guilty this morning of first-degree homicide and a charge of hiding a corpse by a Jefferson County judge.
David W. Throm was found guilty of killing his live-in girlfriend and hiding her body by Judge William Hue.
Hue convicted Throm of the two charges after listening to testimony throughout the week. Opening arguments got under way Monday morning and approximately 28 witnesses testified during the bench trial.
Following the conviction this morning, Throm’s bond was revoked and he was returned to the Jefferson County Jail to await sentencing.
No date for his sentencing has been set.
If a request is filed for a pre-sentence investigation, the sentencing date will be 45 to 60 days from now. If no request is filed, a sentencing date will be held within 30 days.
Throm faces life imprisonment for the death of Colleen Ann Wilke, 39, of Palmyra, whose body was found July 2, 2002, in a remote area about one mile west of County Trunk H on Marsh Road in the town of Palmyra.
Throm was later arrested in Minnesota when deputies responded to an emergency call at a wayside near Blue Earth, Minn. Throm apparently attempted to commit suicide as deputies found a suicide note in his car stating his girlfriend, Wilke, was dead. The note also indicated where Wilke’s body could be found.
Wilke and Throm were not living together at the time of the incident because they had recently broken off their relationship. Both were on the rebound from recent divorces.
Throm’s attorney, Maura McMahon of the state public defender’s office, pursued an involuntary intoxication defense relating to Throm’s prescription to Paxil, an antidepressant drug.
Prior to Paxil, walking away from a situation was Throm’s defense mechanism, McMahon told the judge. Dr. Andrew Schroetner, a psychiatrist form Watertown, testified by video that he had increased Throm’s dose of Paxil on June 7, 2002. Two weeks before Wilke’s body was found and Throm arrested, Schroetner decreased the dosage of Paxil and added a dose of Seroquel.
District Attorney David Wambach presented testimony in which Throm’s care provider described him as angry, wounded and ready to explode. During his opening argument, Wambach referred to a statement Throm had made to Wilke that she “should fear him.”
A Madison pathologist testified Wilke sustained a bruised heart, nine rib fractures, lacerated liver, fractured voice box cartilage and four separate areas of neck hemorrhage.
Several neighbors, friends and family members of Wilke’s testified, including her 14-year-old daughter.
Throm did not take the stand during the trial.
“In a study published this week in the Journal of the American Medical
Association, U.S. researchers found that potentially harmful medication
errors are three times more likely to occur among hospitalized children than
April 28, 2001
Infants at risk from hospital drug errors
Study of medication use
Sharon Kirkey, National Post
Peter J. Thompson, National Post
David U, president of the Institute for Safe Medication Practices, Canada,
says most mistakes in medication stem from “system error.”
Cathy Landry hovered over her son’s hospital bed, trying to comfort him as he
recovered from minor foot surgery. She picked him up, held him, put him down
again. “Please fall asleep,” she whispered to her second-born. “Mommy’s
Hours later, brights lights and commotion roused Mrs. Landry from the
mattress on the floor where she had been sleeping next to the 11-month-old’s
bed. “Is he OK?” she asked the nurses leaning over her baby’s bed. No one
Trevor Landry was dead.
Sometime the evening before, a nurse at the hospital in Brampton, had
mistakenly injected Trevor with two five-milligram shots of morphine. His
doctor had prescribed Demerol. The morphine shut the boy’s respiratory system
down. He died of cardiac arrest. Jurors at his three-week inquest ruled
Trevor’s death a homicide.
Every year in Canada, an estimated 500 to 700 people die from medication
errors while in hospital.
No one knows how many of those deaths – or how many near misses — occur in
children. But a new study suggests it happens more often than people had
In a study published this week in the Journal of the American Medical
Association, U.S. researchers found that potentially harmful medication
errors are three times more likely to occur among hospitalized children than
The researchers detected 616 medication mistakes out of 10,778 orders written
over a six-week period at two large teaching hospitals — Children’s Hospital
Boston and Massachusetts General Hospital for Children.
The overall error rate of 5.7% was similar to what has been found in studies
of adults, but the number of errors that had the potential to harm was three
times higher, and they most often occurred in the youngest, most vulnerable
patients — newborns in the neonatal intensive care unit.
“These potential adverse drug events are best thought of as near misses or
close calls,” says the study’s lead author, Rainu Kaushal, an internist and
pediatrician at Brigham and Women’s Hospital in Boston. “Either the system
intercepts them before they reach the patient, or we’re just fortunate the
patient doesn’t suffer any [harm] to them.”
While the study involved American hospitals, there is no reason to believe
the findings would be any different had the hospitals been in Canada, experts
“We don’t have any reason to believe we’re any safer,” says David U,
president of the Institute for Safe Medication Practices, Canada, an
independent group that is pushing for a national reporting system for
The Boston researchers believe nine out of 10 medication errors could be
prevented with simple reforms, such as computerized ordering systems that not
only eliminate one of the leading causes of mistakes — a doctor’s often
indecipherable handwritten scrawl — but alert doctors if, for example, the
dose being prescribed is too high or too low based on the child’s weight, or
if there is a risk the drug will interact dangerously with another medication
the child is taking.
The report is the latest to highlight a problem critics say has been kept
hidden too long. Two years ago, a landmark report by the U.S. Institute of
Medicine put the human toll of medical mistakes in hospitals at 98,000 deaths
a year. Extrapolated to Canada, that means about 10,000 people a year may die
as a result of care provided to them in a hospital.
But for years the attitude has been, “hide it, suppress it, don’t tell
anybody,” says Dr. John Millar, vice-president of research and population
health at the Canadian Institute for Health Information in Ottawa. That
culture was driven by fear of lawsuits and a closed profession, Dr. Millar
says, in which “doctor knows best and the doctors will review [mistakes]
themselves and take whatever necessary action to fix it.”
While the culture is changing — “fast,” Dr. Millar says — the result is
that no one can say with any certainty just how often medication errors occur.
And children, especially critically ill children, are the most vulnerable.
Children do not have the same internal reserves an adult does to absorb the
impact of a medication error. Take a premature baby in the neonatal intensive
care unit, Dr. Kaushal says. “Their kidneys and livers aren’t as well
developed, so if there’s even a small overdose, they can’t deal with it in
the same way” as a healthy baby. And babies can’t communicate. “So if a small
child has a side effect, for example, they’re itching [because] of a drug,
they can’t tell us.”
If Dr. Kaushal sees an adult with an ear infection, she prescribes 500
milligrams of a penicillin drug. “When I see a child, I have to take their
weight in pounds, convert it to kilograms, calculate a milligram per kilogram
dose for 24 hours, divide that by the frequency, and then I have the dose.”
Pharmacists have to dilute stock solutions or divide pills. The same drug can
be available in three different concentrations. Something as simple as poor
lighting can lead to labels being misread.
Potentially lethal mistakes are often discovered before the drug can be
given, but not always. Last week, a nine-month-old girl died in a Washington
children’s hospital because of a misplaced decimal point. Instead of
receiving two 0.5 milligram doses of morphine, the child was given two doses
of 5 milligrams each, or 10 times what the doctor had intended. According to
newspaper reports, the doctor had failed to follow hospital procedures
requiring him to put a zero before the decimal point.
In the study published this week, 18 of the mistakes that were detected
before the drug was administered were potentially life-threatening.
The researchers studied medication order sheets, drug administration records
and patient charts from 1,120 children admitted to the two hospitals during a
six-week period in April and May of 1999. They found 115 potential adverse
drug events (or “near misses”), and 26 adverse drug events. None of them was
In many cases, errors were minor, such as a doctor’s failure to date a
prescription. But the most serious errors, such as prescribing the wrong
dose, occurred most often in the neonatal intensive care unit, where a baby’s
weight changes rapidly, making appropriate dosing particularly difficult, the
authors said. In addition, many of the drugs used in the ICU are not supplied
in dosages suitable for newborns and have to be diluted.
While the “near misses” accounted for only 1.1% of all errors detected, the
researchers say it was still three times higher than among adults. Most
involved incorrect doses. Others involved not specifying how a drug should be
administered, or a patient with an allergy to a drug, for example,
penicillin, being prescribed a penicillin-based medication.
The researcher said 93% of the errors could have been prevented with
computerized order entry systems and having pharmacists work full-time on
hospital wards. “The idea is to take pharmacists out of the pharmacy and
place them on wards so that they’re involved in rounds, they are involved in
decisions when they’re being made about what medicine to use and what dose
and what route” to give the drug, Dr. Kaushal said.
Some hospitals in Canada, including the Hospital for Sick Children in
Toronto, now use computer order entry systems and pharmacists on many units.
Still, it is estimated that fewer than 5% of hospitals in Canada do so.
Dr. Kaushal says he does not want parents to be alarmed. “These were two of
the finest pediatric hospitals in the country,” she said of the hospitals in
her study. But there are things parents can do, she said, to reduce the risk
of their children suffering a medication error while in hospital.
“Know why your child is on the medicines they’re on. Be a strong advocate for
your child. If you notice that one day your child is given a specific
medication twice and the next day they’re given that medication four times,
ask someone why that’s happening.
“If you think your child is having a side effect to a medicine, tell someone.
Often a parent is the first one who can pick up on something like that. If
your child seems to be a little itchy or seems to be irritable after getting
a medicine, let somebody know.”
David U, of the Institute for Safe Medication Practices, says in most cases
medication errors result from a “system error,” not any one individual’s
mistake. But he said hospitals need to take their cue from the airline
industry and encourage people to report when an error has been made without
fear of being punished and challenge authority when they see potential
“In the airline industry, the pilot used to call the shots on everything. Now
the co-pilot or first officer has the right to stop the plane from flying or
landing if they find one of the conditions is not right. It should be the
same thing for health care, and it is starting to change.”
While hospitals have their own system for tracking and recording errors, “by
and large the reporting is done for statistical purposes,” he says. And the
information isn’t usually shared with other hospitals, “so next week you can
have a hospital one mile away have the same event happen.
“We need to set up a voluntary reporting system so that people can let us
know what’s happening out there, we can analyze the information, send it back
to the hospitals and learn from it so we can prevent these problems from
Not a day, “not a second,” goes by that Cathy Landry and her husband,
Michael, do not think of Trevor, who would have started junior kindergarten
“I’m trying to say, ‘to err is human.’ But it’s very frustrating. It’s
maddening. It’s hurtful to know it happens every day to so many children,”
Mrs. Landry says.
Although her baby’s death in a Brampton hospital in June, 1998, was declared
a homicide, the verdict did not imply blame or intent on the part of the
nurse. According to reports, stress and fatigue may have played a role. The
inquest heard that at one stage two nurses were caring for 18 children on the
Trevor had been admitted for elective surgery to correct his club feet. “It
was routine surgery. We were supposed to be in and out,” his mother said. The
night before he died, she remembers how her normally verbal, active baby
wasn’t himself. “He was very quiet, kind of fussing.” When the nurses woke
her up and she looked down at her son, he was blue. “He looked choked. He was
on his back. It was awful.” The doctors and nurses spent 30 minutes trying to
get Trevor’s heart beating again.
“Every day we mention his name. Every day we talk about him. Everything
reminds me of him; everything connects with him,” Mrs. Landry says.
She believes every hospital should have to make public its rate of medication
errors. “I should be able to look at two or three hospitals’ records,” she
“That should be handed to me: ‘Here, you decide.’ “