ANTIDEPRESSANT: Suicide: England

Second paragraph reads:  “Steven Rodgers was found dead in his bed after overdosing on prescription drugs for a heart condition and depression.”

http://www.sunderlandecho.com/news/Lovesplit-torment-ended-in-tragedy.5524741.jp

Love-split torment ended in tragedy

Published Date:
05 August 2009
By Lisa Nightingale

A father killed himself after falling into depression contributed to by years of problems with his estranged wife, an inquest heard.

Steven Rodgers was found dead in his bed after overdosing on prescription drugs for a heart condition and depression.

He was discovered on February 3 by new partner Susan Redmayne who had let herself in to his flat in Front Street in East Boldon.

She had become concerned for his safety after he failed to turn up to his job as assistant manager at Morrisons in Seaburn and she was unable to contact him.

Miss Redmayne, said: “I went in and saw the dog and two letters. I looked on the table and his car keys were still there.

“I began searching for him and the last place I went into was the bedroom and that’s where I found him.

“I went up to him and touched him, he was stone cold.”

Yesterday, an inquest into his death heard results from a toxicology report showed Mr Rodgers had levels of propanol, a betablocker, and mirtazapine, an anti-depressant, at levels where either one was “sufficient enough to cause sudden death”.

Coroner Terence Carney was told by Mr Rodgers’ sister, Kathleen, how after the 44-year-old, originally from Sunderland, was diagnosed with angina he had felt more tired but had carried on working.

He was also going through the process of a divorce after 10 years of marriage. The separation had been acrimonious and for the past two years he had endured late-night visits and phonecalls from his estranged wife.

He was also worried about his finances after falling behind with debt payments.

Miss Rodgers, said: “He would stay in a lot as he was frightened Pauline would cause trouble. She had been down to his works recently.

He used to laugh it off as he didn’t want us to worry.

“He wouldn’t go into details but he always said she was hanging around and knocking on his door, sometimes at 4am.”

Miss Redmayne told Mr Carney how the police and bomb squad were called out on two occasions after he found mobile phones taped underneath his vehicle.

A police officer attending the inquest said she had no knowledge of these calls.

Miss Redmayne added: “I just felt he couldn’t take anymore. He had just hit rock bottom.”

Mr Carney, said: “There is no doubt in my mind this was a man who for some considerable time and more recently has been suffering from acute depression.

“It appears that his domestic situation was the factor of much of that depression and I agree with the evidence I have heard from family for some considerable time he was suffering ongoing anxiety and pressure of an unresolved domestic situation.

“Clearly the effects in my view of that ongoing stress have impacted greatly on this man’s decision to ultimately kill himself.”

Speaking after the inquest, Mr Rodgers’ estranged wife, Pauline, of Herrington, said she was too distraught to attend yesterday’s inquest and didn’t want to upset the rest of Steven’s family.

She added: “I was upset when I found out he had a heart attack. I was past myself.

“To find out he had really acute heart problems was upsetting. You can’t be with someone all those years and not feel anything, and I do.”
Mr Carney gave a narrative verdict and recorded his death was as a result of taking propanol and mirtazapine.

He also recorded that he self-administered these drugs, consequently killing himself, and that at the time he was suffering from acute depression.

Speaking after the inquest his family said Steven was “one in a million”.

The full article contains 615 words and appears in Sunderland Echo newspaper.
Page 1 of 1

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CELEXA: Death: Probably a Suicide: Day After Leaving Hospital: England

Paragraph nine reads:  “Consultant pathologist Dr Dariusz Golka said the cause of death was overdose of the anti-depressant citalopram  [Celexa].”

http://www.blackpoolgazette.co.uk/blackpoolnews/Man-took-overdose-a-day.5545843.jp

Man took overdose a day after hospital

Published Date: 12 August 2009

A MAN died from a fatal overdose less than 24 hours after being released from hospital, an inquest heard.

Philip John Bromley, of Handsworth Road in North Shore, was found on his kitchen floor by his daughter on the morning of July 29, 2007.

An ambulance was called, but paramedics could not save the 40-year-old former civil servant.

Blackpool Coroner’s Court was told the previous day he had taken anoverdose of blue tablets – later revealed to be benzodiazepines he had bought on the street – crushed up into a drink.

His daughter had called an ambulance after finding him seeming like he was drunk, “slurring” and with blue staining on his lips.

He was discharged from hospital later that night.

The locum doctor who treated him had told the inquest Mr Bromley, who suffered mental health problems and was under the crisis team from Lancashire Care Trust, said his observations, clinical condition and blood samples were normal.

Mr Bromley was seen by the mental health night practitioner at the hospital, who stated in a report about the incident he had assessed Mr Bromley and although he indicated he had on-going difficulties, he denied any suicidal intent.

Consultant pathologist Dr Dariusz Golka said the cause of death was overdose of the anti-depressant citalopram.

Coroner Anne Hind said she could only record the verdict Mr Bromley took his own life. She said: “It is very concerning how easily available such drugs are.”

The full article contains 251 words and appears in n/a newspaper.
Page 1 of 1

  • Last Updated: 12 August 2009 9:47 AM
  • Source: n/a
  • Location: Blackpool

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ANTIDEPRESSANT: Suicide: Man Shoots Himself: England

Paragraph 8 reads:  “Mr Hobbs, who had been diabetic for 10 years, died on May 17 from a traumatic head injury, five days after being prescribed anti-depressants.”

Last paragraph reads:  “Coroner William Morris recorded verdict of suicide.”

http://www.ely-standard.co.uk/content/ely/news/story.aspx?brand=ELYOnline&category=News&tBrand=HertsCambsOnline&tCategory=newslatestELY&itemid=WEED04%20Aug%202009%2018%3A26%3A19%3A740

Soham Man Who Was Depressed After Losing His Job Shot Himself At Home

18:21 – 04 August 2009

coroner’s court
DISTRAUGHT and depressed after losing his job, JCB driver John Hobbs shot himself in the garden of his Soham home.

Just one day after being made redundant, 63-year-old Mr Hobbs went into a deep depression.

“From that day, the John I knew and loved was gone, and we began to argue,” his loving wife Gwendoline told an inquest at Ely Magistrate’s Court on Tuesday.

“He was anxious and desperate to find a new job,” she said in a statement to the coroner. “He started to worry about bills and money, because he only received Job Seeker’s allowance.”

Mr Hobbs was so desperate to get a new job, that he even approached members of the public in the doctor’s surgery car park, asking for a job, said Mrs Hobbs.

He lost nearly two stone in weight over a 10-week period. “He looked gaunt; he was a shell of himself.

“His behaviour became worse, and he said he wished he was dead.”

Mr Hobbs, who had been diabetic for 10 years, died on May 17 from a traumatic head injury, five days after being prescribed anti-depressants.

Mr and Mrs Hobbs had been married for 43 years, and lived together in Cornmills Road at Soham.

“Sometime in the afternoon I heard a very loud bang from the rear garden, it sounded like a shotgun, I was very worried,” said Mrs Hobbs in her statement.

He started work for Bradford Properties in 1967; he was very proud of his job, and always eager to get work.

After being diagnosed with diabetes, Mr Hobbs struggled with his weight, and found taking his medication a chore.

He was looking forward to retirement, but in December last year was given 12 weeks’ notice, and even offered to work for half pay.

Coroner William Morris recorded verdict of suicide.

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ANTIDEPRESSANTS: Suicide: Man Out of Prison for 3 Hours: England

Notice from the article below that this fellow had been abruptly discontinued from his antidepressant when incarcerated in November. Then while still in the critical withdrawal stage was re-introduced to the use of an antidepressant – likely a new one since jails and prisons have access to a select few they prescribe. So he likely had three strikes against him leading to his sudden and very determined suicide.

Dr. Ann Blake-Tracy, Executive Director, International Coalition For Drug Awareness

Paragraph four reads: “The jury inquest at Nottingham Coroner’s Court heard Mr Brown had been at the prison for five weeks and was four days away from being released when he was seen by a psychiatrist and given anti-depressants.”

SSRI Stories note: The most likely time for suicidal behaviors and SSRI antidepressants are: 1. When first starting the drugs: 2. When stopping the drugs. 3. While increasing the dose: 4. While decreasing the dose. 5. When switching from one SSRI to another antidepressant.

http://www.thisisnottingham.co.uk/homenews/Coroner-criticises-healthcare-Nottingham-Prison/article-1196220-detail/article.html

Coroner criticises healthcare at Nottingham Prison
Monday, July 27, 2009, 07:00

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A CORONER has criticised health services at Nottingham Prison after an inmate committed suicide hours after his release.

Gary Brown, 39, of Cranwell Road, Strelley, drowned on December 24, 2007.

He was seen jumping off Trent Bridge less than three hours after he was released from the prison.

The jury inquest at Nottingham Coroner’s Court heard Mr Brown had been at the prison for five weeks and was four days away from being released when he was seen by a psychiatrist and given anti-depressants.

Notts coroner Dr Nigel Chapman said there was a “huge gap” between Mr Brown seeing a GP on his arrival at the prison and seeing a psychiatrist.

The inquest heard there was a lack of communication between health workers, and one doctor at the prison called it “an entirely haphazard system”.

Mr Brown arrived at Nottingham Prison on November 15, 2007. He saw a GP, Dr Lloyd, the next day, who said Mr Brown was not showing symptoms of mental health problems.

Mr Brown said he had previously been prescribed anti-depressants but Dr Lloyd did not renew the prescription as he could not obtain any previous medical records.

Other members of the health team said they tried to get hold of Mr Brown’s medical records but were unable to trace them.

Dr Julian Kenneth Henry, who also saw Mr Brown, told the inquest the amount of time between the prisoner arriving and seeing a psychiatrist was “unprecedented”.

He said: “Unfortunately, in a prison setting there are an awful lot of people involved and there are failures of communication on a daily basis.

“It’s an entirely haphazard system. It’s a very disjointed system and there is not an excuse for it.”

Mr Brown saw psychiatrist Dr Trevor Boughton on December 20 and was given a prescription for anti-depressants.

Dr Boughton said Mr Brown seemed anxious but not psychotic or suicidal.

He said: “He seemed very eager to be released from prison. He spoke very fondly of his brother, whom he was hoping to spend Christmas with.”

The inquest heard the medication was not likely to have had any effect on Mr Brown by the time he was released four days later.

Senior prison officer Vince McGonigle said Mr Brown was released between 9am and 9.30am on December 24 and seemed “in an agitated state”.

Less than three hours later, at around 11.45am, a member of the public saw him jump from Trent Bridge into the River Trent.

Kyle Charles told the inquest: “I saw a person in the water and tried shouting at him. I managed to get the orange ring off the wall and threw that into the water but he swam away from it.

“When he saw me taking my jacket off he held his nose and then started to push himself under the water. He went down, came back up, went down and never came back up again.”

Mr Brown’s body was pulled from the water at 2.55pm. There was no evidence of any violence and no alcohol found in his system.

The jury returned a verdict of suicide, with a majority of six to two. They said there had been a “severe breakdown” of communication during Mr Brown’s care.

Coroner Dr Chapman said: “Clearly there have been difficulties here and the prison has taken those on board.”

But he said Mr Brown’s time in prison would have been a good opportunity to put him on medication and monitor him.

He added “a simple phone number” for a crisis team would be beneficial for people leaving prison.

samantha.hughes@nottinghameveningpost.co.uk

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4/29/2001 – Infants at [greater] risk from hospital drug errors

“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
in adults.”

http://www.nationalpost.com/

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
tired.”

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
answered.

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
believed.

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
in adults.

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
say.

“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
medication errors.

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
fatal.

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
mistakes occurring.

“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
happening.”

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
in September.

“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
ward.

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
says.

“That should be handed to me: ‘Here, you decide.’ “

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