John Abrahams: Prevention of future deaths report

Prevention of Future DeathsSuicide (from 2015)

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Date of report: 14/02/2023
Ref: 2023-0058
Deceased name: John Abrahams
Coroner name: Catherine McKenna
Coroner Area: Manchester North
Category: Suicide (from 2015)
This report is being sent to: Department of Health and Social Care

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
 THIS REPORT IS BEING SENT TO:
Secretary of State for Health and Social Care
1CORONER  
I am Catherine McKenna, Area Coroner for the Coroner area of Manchester North
2CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
3INVESTIGATION and INQUEST
On  31  August  2021  an  Investigation  into  the  death  of  John  Abrahams  (Jack) was commenced. The investigation concluded at the end of the inquest on 10 February 2023. I recorded a conclusion of Suicide.
4CIRCUMSTANCES OF DEATH
Jack Abrahams was 20 years old when he took his own life by means of self-ligature. J heard evidence that when Jack was 17 years old, he had received a six month course of lsotretinoin (brand name Roaccutane) for treatment of acne. The available evidence did not meet the standard required to show a causative link between the course of treatment and Jack’s suicide.
5CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTER OF CONCERN is as follows:

The Commission for Human Medicine (CHM) established an lsotretinoin Expert Working Group (IEWG) in response to concerns about psychiatric events. The IEWG considered oral and written evidence over 2020 and 2021. The findings and recommendations of the IEWG were presented in a report to the CHM at the end of 2021 and include a recommendation which relates to prescribing for patients under the age of 18.  

It is now over a year since the IEWG report was completed and the recommendations have still not been implemented. In that time there have been 45 adverse lsotretinion events reported to the Medicines Healthcare products Regulatory Agency (MHRA) comprising of 81 psychiatric adverse events, one of which was an attempted suicide. The Court heard that a second working group is required to consider how to implement the IEWG recommendations and that this group has yet to meet.
6ACTION SHOULD BE TAKEN  
In my opinion action should be taken to prevent future deaths and  I believe  each of  you respectively have the power to take such action.
7YOUR RESPONSE  
You are under a duty to respond to this report within 56 days of the date of this report, namely 12 April 2023, I, the Area Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
8COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:
•        The family of Jack Abrahams
•        The MHRA

I am also under a duty to send the Chief Coroner a copy of your response.
 
The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.
9Date:  14 February 2023