Vietnamese community prays for Edmonton murder victims, forgives killer — (The Globe and Mail)

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The Globe and Mail

Reader’s Letter — (SSRI Stories)

December 12, 2014

Reader’s Letter to SSRIStories:

I need to talk for all the children, teens, women and men who died from antidepressants, and for those who are suffering because of them.    Here is my story:

I ‘ve been depressed since my teens because of bullying in school.  I started taking pills to treat it in 2011.  I took citalopram for 3 years and my depression get worse.  I was so depressed I wanted to die.

After those 3 years I thought Cymbalta would resolve all and that the former drug was ineffective.  I felt well at first under Citalopram but then my depression get worse than ever.  With Cymbalta it was the same story: at first I was well and then my depression get worse than ever.  I was in hospital for a month for suicidal thoughts and deep depression.  I was at the point of  wanting to kill myself.  They put me back on 60 mg and then 90 mg of Cymbalta, even though the doctors should have known that the drug was not effective. But at that time I trusted the doctors and I never thought that the antidepressants were causing my depression, and the suicidal thoughts, anger, and paranoia.   So same story again… At first I felt better with the Cymbalta but when they increased the dose I got worse again.

This time, I decided to stop taking the antidepressant after doing some research and finding out the truth about these drugs.   I am now taking 60 mg instead of the 90 mg my doctor prescribed, to try to get off this drug gradually.

The doctor is not sure if it is good to reduce it further as the withdrawal effects affect my health.  I can’t walk easily, all my muscles hurt, I have nausea, dizziness,  and I’m so tired I sleep all day but I’m really motivated to stop this drug and to not taking anymore pills.

I’ve created to alert people to the dangers and truth behind those psychiatric drugs.  These drugs ruined my life.

Mental health care system failed ‘low-risk’ suicide mother of two — (The Gloucestershire Review)

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The Gloucestershire Review

Thursday, 23 October 2014

THE DISTRAUGHT family of a 39-year-old woman who hanged herself after being assessed as a low suicide risk have lashed out at the mental health treatment the mum-of-two received.

After an inquest into the death of Victoria Phelps of Wilton Road, Gloucester on August 6th, 2012, the mother of the deceased, Gayle Tucker said: “After one of her suicide attempts I begged that my daughter be sectioned so that she could be looked after properly.

“To say someone is at a low risk of suicide when she has made previous attempts is just not on. My daughter has been let down.”
Victoria’s brother Brett Phelps added: “My sister only started having suicide thoughts and making attempts when she was prescribed Fluoxetine. I’ve been doing some research into the drug and reckon that it was a death sentence for my sister.”

Senior Coroner for Gloucestershire Katy Skerrett said: “It is quite clear that from 1992 this lady suffered on-off with anxiety. She was a working lady with two sons and had been taking anti-depressants since 2000.   “In April 2012 things came to a head due to a relationship breakdown and this triggered events in a bad way.”

Victoria took a drug overdose and was admitted to Gloucestershire Royal Hospital. She then waded into a canal and spoke to friends about ending her life, the inquest at Barnwood was told.   Police Constable Karen Raistrick told the inquest: “I attended her home on a previous occasion when she tried to hang herself in the garage and I was on duty when I was again called to the house on August 6th that same year, but this time we found her dead.”

Victoria’s son had handed police a key to the garage and was just prevented in time by a friend from walking in and seeing his mother hanging by a dressing gown cord.   Despite the previous history of anxiety and depression and suicide attempts, which included superficially cutting her wrist, mental health liaison nurse Julie Nicholson assessed her as being at low risk of self-harm “but this increased when alcohol was consumed.”

In a written statement to the inquest the nurse said that the family was asked to look after her medication “to reduce the risk of overdose.”   “The patient did not want to die but told me that she would sometimes drift into a tunnel,” said the nurse. “She seemed flat and worried.”

Ms Skerrett reiterated the deceased’s recent mental health history: depression after an aunt died in 2005, anxiety in 2007 and 2008, panic attacks in 2009 and 2011, overdose and hospital admission in 2012, insomnia after relationship breakdown the same year, depressed and suicidal thoughts in July 2012.

She was referred to psychiatrist Prakash Muthu for a crisis assessment in July 2012 and he gave evidence at the inquest yesterday.   “She told me about the overdose and the episode wading into the canal and also the cut wrists but she clearly regretted her actions, felt scared of what she had done and wanted help,” said the psychiatrist.   “But she told me that she had no more suicidal thoughts and I assessed her as being of low risk of suicide. She maintained good eye contact during my assessment and seemed to be looking to the future.”

Dr Muthu said that he recommended a change in medication and told her that, as part of her risk management, she should contact The Samaritans. But the psychiatrist denied that there was an increased risk of suicide associated with Fluoxetine.

Ms Skerrett concluded that she could not be sure that Victoria intended to take her own life and there was reasonable doubt.   “This may have been a cry for help and I will give a narrative conclusion,” she said.    After retiring for ten minutes the coroner returned to the courtroom and delivered her narrative conclusion: “This 39-year-old lady was suffering from depression and anxiety, triggered by a relationship breakdown in March 2012.   “She made a few suicidal attempts in the weeks preceding her death. However it is unclear whether she had formed a clear intention to die.”

All content © of Gloucester Review unless stated otherwise.

Magnotta complained of hearing voices, being stalked, doctor testifies — (The Globe and Mail)

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The Globe and Mail

Sidhartha Banerjee

Robin Williams — Suicide Triggered by Depression, Parkinson’s, Paranoia — (

By Caroline Graham for Mail On Sunday

A close friend of Robin Williams has blamed the drugs the comedian was taking to combat Parkinson’s disease for his suicide.

Actor Rob Schneider tweeted: ‘Now that we can talk about it #Robin Williams was on a drug treating the symptoms of Parkinson’s. One of the side effects is suicide.’

Schneider, 50, met Williams more than two decades ago when they appeared on the US TV show, Saturday Night Live. They remained close friends and often performed together in stand-up comedy clubs.

Williams’s spokeswoman declined to comment when asked by The Mail on Sunday about rumours that the tragic comic’s family blames the medication he was on for ‘pushing him over the edge’.

A source said: ‘Robin had recently left rehab. He was on medication for anxiety and depression and had also started taking drugs to combat the early onset of Parkinson’s.

‘Many of these drugs list suicidal thoughts as a possible side effect. A lot of Robin’s friends are convinced that the cocktail of prescription pills he was on somehow contributed to his mental state deteriorating as quickly as it did.

‘Robin had always suffered from depression and addiction but the diagnosis and treatment of his Parkinson’s was new, as was the combination of drugs he was on.’

Williams, 63, was last photographed at an art show near his home in Tiburon, northern California, last Saturday night. He appeared frail and thin.

He took his life last Sunday as his third wife Susan Schneider (who is not related to Rob Schneider) slept in the next room. The pair are thought to have been sleeping in separate rooms because Williams was suffering from insomnia brought on by the drugs he was taking.

Williams’s body was found on Monday morning by his personal assistant. Results of toxicology tests are expected to take six weeks.

Experts say Parkinson’s disease can make symptoms of depression worse.  America’s National Institute of Mental Health says on its website that people struggling with depression and Parkinson’s ‘suffer higher levels of anxiety and more problems with concentration’ than those suffering from only one of the ailments.

Dr Jeff Bronstein, neurologist specialising in Parkinson’s, said: ‘Obviously getting the diagnosis can make people depressed but we also know there is a much higher incidence of depression even before the disease is recognised. We think it’s one of the early symptoms.’

The funeral of the star of Good Will Hunting, Good Morning Vietnam and Mrs Doubtfire could take place as early as this weekend.

A source told The Mail on Sunday: ‘The funeral will be private and small for family and very close friends only. There will be larger memorials in Los Angeles and New York at a later date.’

Williams was involved in raising money for Parkinson’s research through his friend Michael J. Fox’s foundation before he was diagnosed with the disease.

Back To The Future star Fox tweeted: ‘Stunned to learn Robin had PD. A true friend. I wish him peace.’

Actress Lynsey Pow found hanged after battles with cocaine and gambling debts — (London Evening Standard)

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London Evening Standard

An actress who appeared in BBC dramas Waterloo Road and Doctors took her own life after battling drug and gambling problems, an inquest heard.

Lynsey Pow, 34, who also appeared alongside Billie Piper in Secret Diary Of A Call Girl, was found dead at her flat in Honor Oak Park on November 28 last year.

An inquest at Southwark coroner’s court heard yesterday how her husband Ashley House, a Eurosport TV presenter, rushed back home from work after growing concerned about her welfare.

The inquest heard Ms Pow told her husband by phone that she was sorry for her online gambling and that she had bought some cocaine.

She was found hanging, with drugs paraphernalia and open bank statements showing gambling debts nearby. A post-mortem examination found traces of cocaine and alcohol in her body.

Her father, James Pow, had tried to take her to his home in Scotland a month before she died so she could get help with her drug habit.

Revealing a bitter family rift, a statement from Mr Pow read to the court said: “I sought to separate my daughter from her husband after he failed to fulfil his marriage vows to act as a custodian and guardian.”

Dr Johan Hugo, a GP who met Ms Pow on October 13, said she told him that she “felt like a failure” and was using cocaine on a daily basis and had tried to self-harm.

Ms Pow was prescribed anti-depressants and referred for psychiatric treatment. When she met Dr Hugo on October 30 she told him she was off drugs and seemed like a “different person”, eager to get back to her life in London and work commitments.

Her brother, actor Duncan Pow, told the inquest that his sister had twice previously tried to take her life. On October 16, he and his younger sister, Kathryn, found her in a “catatonic” state. The inquest also heard how Ms Pow left a note before her death.

Assistant Coroner Sarah Ormond-Walshe recorded a narrative verdict, saying the presence of drugs in Ms Pow’s system meant it could not be proven she intended to kill herself.

She said: “[Ms Pow] appeared to have obtained some cocaine and while under the influence of cocaine she appeared to hang herself.

“It is likely to have influenced her mind so it cannot be said that she intended to die. I am recording this as a drug-related self-harm death.”

Ms Pow’s father said he was pleased the coroner did not record a suicide verdict as he blamed his daughter’s death on her relapse into drugs.

Mr Pow, owner of the Country Attire clothing company, told the Standard: “She was getting better. The tragedy is that she could have been saved. We did everything we could when we found out about the drugs. Lynsey touched so many lives. There were 1,400 people at her memorial service. The only thing that has helped is that it has brought our family even closer together.”

Mr House declined to speak at the inquest and declined to comment when approached by the Standard.

Olympia woman pleads guilty in 2013 murder — (The Olympian)

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The Olympian 

By Amelia Dickson, Staff writer

November 6, 2014

The woman accused of killing a former Behavioral Health Resources employee in 2013 pleaded guilty to second-degree murder during a Thursday morning appearance in Thurston County Superior Court. She also entered guilty pleas for three counts of second-degree assault and one count of taking a motor vehicle without the owner’s permission.

Lia Y. Tricomo, a 28-year-old Olympia resident, strangled and slit the throat of her former counselor, John Alkins, after the two had sexual relations at his Sunset Beach Drive home. Tricomo will likely be sentenced in December and she could receive up to 29 years, 9 months in prison. She has been held in the Thurston County Jail since she was arrested May 1, 2013. BHR had fired Alkins in December of 2012 after he “violated BHR policies concerning professional boundaries,” but failed to report the termination to the state. In June of 2013, the state Department of Social and Health Services fined BHR $1,000 for failing to report the incident. The company released a statement from CEO John Masterson on Thursday afternoon. According to the statement, Alkins worked for BHR for 20 years before he was fired. “John’s murder is a genuine tragedy and those of us that knew him continue to grieve his untimely and unnecessary death,” Masterson wrote. Tricomo told Thurston County Sheriff’s detectives that she and Alkins had stayed in touch after he was fired, and that she moved into his house April 29, 2013. Court documents give the following account of the events leading to her arrest: The Thurston County Sheriff’s Office began investigating Alkins’ death on April 30, 2013, after Tricomo called BHR and told an employee that she had stabbed a man the night before. Deputies arrived at the home, at 3814 Sunset Beach Drive NW, and saw blood smeared throughout the house. They found Alkins upstairs in the master bedroom, lying face down on the bed with an extension cord wrapped around his neck. A large pool of blood was on the floor next to the bed. Detectives learned that Tricomo was at Providence St. Peter Hospital. Tricomo told detectives that after she moved into Alkins’ home, he bought her a bottle of vodka and they began drinking that afternoon. The two began having sexual contact that evening. Tricomo said the contact was unwanted, but she never told Alkins “no.” The couple moved to the master bedroom, where Tricomo tried to tie Alkins up. He declined, and she slit his throat with a razor. She told detectives that she hid the razor in the room in the hopes of killing Alkins. When asked why, she said he was a creep. Tricomo said she followed Alkins around the house for several hours, and eventually strangled him with a green extension cord. She then drank more vodka and went to bed.

Olympia woman pleads guilty in 2013 murder | Crime | The Olympian 

The next day, she called BHR to report that she had stabbed someone. She then took Alkins’ car and drove to an Alcoholics Anonymous meeting in downtown Olympia, where she asked for help. A member of the group drove her to Providence St. Peter Hospital.

Amelia Dickson: 360-754-5445 @Amelia_Oly

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Mcalester matters

Dec 12, 2014


One year after the Iraq war started, my young and innocent daughter Lia was invited to an Iraqi wedding party, as violin entertainment, along with her sweet little sister, just outside of Illahee State Park in Bremerton, Washington; by an Iraqi man. I told them even though we were at war, Iraqi people are nice. I still believe that for the most part.  Lia was only 17 and her sister was 15. After performing, they were given copious amounts of alcohol, and taken out into the park and violently gang raped by members of the wedding party; under two different trees. As they were being dragged away from each other; toward the two trees; my 15 year old called out to her sister; “Where are they taking us?” Lia called back “I THINK THEY ARE RAPING US!” They reportedly attempted to communicate to console each other during the ordeal.

They both refused to have charges brought; because they feared it would only prolong the damage that had been already done. They were treated thanks to Planned Parenthood; just after the rape. Their mother and I wouldn’t be informed of it for two turbulent years! They only told us they had been given alcohol at the party, and had crashed the scooter.  Their legs were cut and bleeding; and they both got MRSA boils around the wounds on their legs; crashing in the escape.

THE DAMAGE HAD BEEN DONE. Bringing the men to justice couldn’t help they reasoned. Lia became depressed and suicidal, attempting to take her own life many times over the years after the vicious rape. She was in and out of hospitals and lock down mental facilities many times afterword. We all thought “Now she is finally in the system; they will help her!” They would keep her under “observation” for a few weeks; and kept letting her go until her next suicide attempt; saying she was fine,  (implied) even though she had stabbed her wrist with a pencil once while in;  while under medication! She was always telling us the drugs made her feel worse.

The deceased was her MENTAL HEALTH COUNSELOR. A “professional” that preyed on vulnerable female patients; He was fired the December before his death, for having been found victimizing another vulnerable female patient. The clinic initially lied about the reason for his dismissal; and were fined $1000 by the State. Although we were unaware of this he continued to see my daughter and invited her to live with him; but wanted her for his own twisted sexual pleasure.

I never met him or spoke with him. He never made any attempt to contact me and Lia wouldn’t allow it. Lia spoke of him on the phone, as her “friend John” (not her counselor) who would take her to sex clubs in Seattle.

Having sex with his rape-traumatized client in public; yet I didn’t know where; but she assured me it didn’t mean PUBLIC, public; until this story correction as of Nov 16, She had told me he was taking her to sex clubs; but I just learned it was an “S and M” group in Tacoma, Washington.  Taking a client to such a place is totally unethical, but shockingly NOT illegal. They put a lot of pins in her back. My other daughter said these images of her back, were online but I never saw them.  It wasn’t something I could even entertain putting in my memory.

It got me thinking a lot more about what I knew about her relationship with her counselor. I had to get to my job was just headed out the door sometime in 2009 or 10; and she showed me her hand with a needle clear through the fleshy part between her thumb and forefinger. “It doesn’t hurt.” she said. “My friend John taught me how and where to do it. It doesn’t hurt really! It’s a mind over matter thing.” I remember telling her “Go take it out.” as I  went out the door.  I lived in Bremerton and she lived in Olympia at the time. she visited when she could and phoned me at times. I wasn’t aware she was in treatment though. She would only tell me she was seeing this guy and that he was over 40, so I just thought he was just some low life… Some  crazy old creep she dug up somewhere. I have lived in Oklahoma for the last 4 years; so information had to be gotten long distance. Harder to piece together.

Crossing boundaries of provider/ client relationship has huge implications; when you figure the mark of a “good” society is measured on the way we treat our most vulnerable; the feeble minded, the elderly, children and mental patients. Did he think his 58 year old penis was the cure for a multiple rape victim? He was a year older at the time than her own father! She was just 27.

On the night before she moved in and killed her former counselor, I got a call that from her, that he had been training her to become a Dominatrix, and had already lined up another ‘client ‘ for her. He asked her to move in with him. She told me he said he wanted to be ‘punished for hurting people as a result of work’. I begged her to move back in with her mother.

The night she moved in; he got her drunk, and she was on the anti depressant Paxil– a bad combination. You know the rest of the story. Sentencing is in December.

This society continues to victimize and vilify women; and it is clear my daughter is being gang raped again by the court; and that of public opinion. I am so sorry for his death; but even death does not absolve his guilt in this, to which my daughter- further victimized by our broken Mental Health system, will pay dearly. She was railroaded into taking a “plea bargain” by the Court team; the Judge; Gary Tabor; who has a history of stiff sentencing for women; the “Defense” and  a two woman Prosecution. She was warned that the sentencing would be stiffer if she went to trial! Someone tried to get the sentencing judge changed, but failed.

She is being charged with 2 counts of murder, and stealing his car to attend an AA meeting where she confessed to the murder; with a maximum sentence of almost 30 years and a minimum of over 20. Still a far cry from their original offer of 50 years. Who had the bright idea of prescribing Paxil?  Another blunder.

Paxil is shown to cause suicide and violence; even murder in some people; (see Paxil warnings after story) and is never recommended for the treatment of anyone who has attempted suicide. It’s effect is intensified if taken with alcohol; and alcohol during withdrawal from the drug can make things even worse!

The State investigation was non existent.  Newspaper reports offer vastly different accounts about physical evidence, and vastly different stories about what allegedly went on.  Authorities only tried to cover up gaping mistakes in her botched care and treatment, and their own “investigation”. There is a real rush to justice, and a lot of blame to go around. I’m sure the State wants this story to never get out; and the media is remaining silent; other than feeding the “She’s a monster” story they want you to hear.

It was not my intention to post this in McAlester Matters; but Facebook removed the post from my wall; then they removed all of the previous McAlester Matters posts from my community page! They restored the stories only after I was forced to post the story on my McAlester Matters blog! It’s no wonder why so many rapes and abuses of women continue to go unreported.

Unbelievably, they don’t even perform a real investigation!  No one ever approached me, to ask me if I knew anything, to be used in her defense. Society seems to just want to write rape traumatized girls off, and be done with it. As a father; I feel nothing but  pain and overwhelming helplessness as she alone is asked to account for all the shame and guilt  for what others have forced on her; and a system stacked against women.

He was training her after all, to be his own personal Dominatrix and It looks to me; he got her too drunk and on Paxil to even know what she was doing. Let’s look at the facts.  Vastly different accounts of a number of cuts on his neck that did not cause his death: but the kind of asphyxiation while engaging in weird sexual activity, that so many are accidentally dying of these days did him in…   The papers wanted you to know is the extension cord she used for this was green.  The message is loud and clear; If your daughter is raped; It’s her fault. There won’t be any help coming to her. She alone, will be left to pick up all her broken dreams.

Farmingdale mom was beheaded by disturbed son two days before meeting with psychiatrist to obtain his medications — (New York Daily News)

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By Nancy Dillon , Ginger Adams Otis

Published: Thursday, October 30, 2014

EXCLUSIVE: Pat Ward, 66, had arranged an appointment on Friday with a psychiatrist to get medications for her 35-year-old son, Derek. ‘He killed my sister because we couldn’t get the prescriptions he needed. For four days, he didn’t have his meds,’ the Rev. Robert Lubrano told the Daily News. Derek Ward had become increasingly unstable in the days before the attack, Lubrano said.

She was just two days away from getting her psychotic son the medication that might have saved her life.

Pat Ward, 66, decapitated in her Farmingdale, L.I., apartment by her mentally ill son, had arranged a Friday appointment with a psychiatrist to get him back on his meds, the Daily News has learned.

Derek Ward, 35, who butchered his mother Tuesday night before taking his own life by jumping in front of a train, was a “sick, sick kid,” according to his uncle.

“He killed my sister because we couldn’t get the prescriptions he needed. For four days, he didn’t have his meds,” said the Rev. Robert Lubrano.

“She’s dead because he had a mental illness, and we didn’t know how serious it was. We’re in terrible shock. She was a wonderful person.”

Lubrano, also of Farmingdale, described his sister as a gentle, loving mother who tried valiantly to care for her family.

Derek Ward had battled psychiatric problems for the past decade, but he had never been violent, Lubrano said.

“He never raised his hand to her before this. Never had a gun. This is all about mental illness and the difficulty of getting a psychiatrist,” he said.

After Derek Ward killed his mother and cut off her head, he sat with her headless corpse for several minutes inside their gore-spattered apartment, cops said.

Then he dragged her mutilated remains down the stairs to the street. He left her corpse there and walked to the nearby Long Island Rail Road station and committed suicide by throwing himself in front of a train.

“She had an appointment set up for (Friday). She finally met a compassionate psychiatrist, but she’ll never make it to see him,” Lubrano sobbed.

Derek Ward was too old to be covered by his mother’s insurance, and they struggled to find a doctor who would accept Medicaid.

Lubrano said he only found out his nephew had been off his meds when it was too late.

“(My sister) was paying $200 for a 20-minute visit. She did everything to keep Derek alive,” he said.

In the days before the horrific attack, Derek Ward grew increasingly unstable, he said. By Monday night, the family was urging the mother to call police.

“(Pat) dropped a fork Monday while making dinner, and he got mad at her. He said the noise hurt his head. She was begging him to go to the emergency room, but he wouldn’t,” the brother said.

“We tried to convince her to go to police, but she was terrified of the police. She thought they might hurt him.”

Derek Ward did six weeks in a Long Island psych hospital in August 2013, after his maternal grandfather died, said Lubrano.

He started complaining of hearing voices that same night, the reverend said.

But he’d never lifted a finger against his mother, and nobody considered him a violent threat.

“We never got a real diagnosis. We thought it was schizophrenia or depression,” Lubrano said.

When he couldn’t get his sister on the phone Tuesday night, Lubrano got in his car and drove to their Farmingdale apartment.

As he got closer and saw all the streets blocked off, he told himself there must have been a gas leak nearby. When he saw a police officer, Lubrano said he needed to visit his sister.

“He said, ‘Apt. G?’ I said, ‘How did you know?’ ” Lubrano recounted painfully.

“He said ‘Father, I don’t know how to tell you, but her son killed her.’”

Lubrano was stunned and heartbroken — and unable to believe his nephew had done what they said he did.

“I thought I was in a horror movie. Cut her head off? To do what he did to the woman he loved the most in this world, his mommy? Her whole life, she was there for him. She did the best she could,” he said.

Ward’s other son, Robert Ward, had died of a heroin overdose in 1997. She and her husband, John Ward, 63, were divorced, relatives said.

That left just Ward and Derek to care for each other, according to Lubrano.

“My nephew was not a bad person, (just) a sick person. He had ADD and was dyslexic. She taught him how to read, then he became an avid reader, went back to school,” the grieving uncle cried. “He was a really good kid. Whatever happened after my father died, it broke him.”

A wake for Ward is planned for Monday from 3 to 8 p.m. at McCourt & Trudden funeral home in Farmingdale.

The funeral is scheduled for 10:15 a.m. in St. Kilian Roman Catholic Church on Conklin on Tuesday.

A Year Later, Trying to Comprehend a Young Hockey Player’s Suicide — (New York Times)

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Popular East Devon teenager who died after standing in front of a train was suffering from depression, inquest hears — (Exeter Express and Echo)

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Exeter Express and Echo

Popular East Devon teenager George Werb died after standing in front of a train was suffering from depression, inquest hears | Exeter Express and Echo

A talented and popular East Devon teenager died after standing in front of a high-speed train after suffering from severe mental illness and depression, an inquest has heard.

George Werb, 15, from Colyton, was killed he was hit by the train at around 6.50am near Seaton Junction on Friday, June 28, last year.
Popular East Devon teenager George Werb died after standing in front of a train was suffering from depression, inquest hears | Exeter Express and Echo

The inquest at Exeter’s Coroner’s Court heard that George had left a three page suicide note under his bed which was discovered shortly after the tragedy occurred and his parents, Joanne and Justin Werb, felt his suicidal tendencies were often not taken seriously enough by staff at the Priory Hospital in Southampton where he was been a patient in the weeks prior to the tragedy.

In a statement read out to the court, the train driver said he had applied the brakes and emergency brakes immediately on seeing someone walk “calmly and deliberately” onto the tracks in front of the train.

The court heard that after being referred by his GP, George waited around 10 months until his first appointment with a Child and Adolescent Mental Health Services (CAMHS) team member in Exeter. It was a subsequent visit to his GP who referred George back to CAMHS and Doctor Seth diagnosed him as suffering from psychosis involving persistent delusion disorder with depression, which he described to the court as “exceptionally uncommon”.

George’s father explained that the family had noticed a change in George around 18 months before his death, and had witnessed him going from being outgoing and involved in numerous extra-curricular activities including acting, playing musical instruments and karate, to becoming withdrawn.

George was initially prescribed anti-psychotic medication which the court heard he refused to take after three doses. George’s father explained that they noticed a “massive” change in their son from the point he started taking the medication. The court heard that George was extremely distressed at having taken the medication, having researched the effects on the internet, a trait that persisted in line with his condition, from then on.

He was subsequently advised he needed hospitalisation to ensure his safety and for ongoing assessment and treatment. Dr Seth told the court that at the time, he would have to phone 20 – 30 units to find out where there is availability for a new patient because there is a shortage of beds.

The closest unit was Plymouth but there was no room so the closest hospital with availability was at Huntercombe Hospital in Maidenhead which George’s parents removed him from after visiting him three weeks later. They said his room was “not fit for a dog”, his bed had no sheets on it, the curtains were short, he still living out of his suitcase and he looked disheveled and unclean, and discovered another patient had threatened to kill George.

After returning home for a short period, George was sectioned and admitted to the Priory, where staff were “very kind”.

Giving evidence, George’s parents spoke of their dissatisfaction over the lack of communication from hospital staff particularly that, they say, they were not advised that suicidal tendencies could increase as a possible side effect of the anti-depressants he was soon prescribed.

The court heard that George has tried to take his life at the hospital but his parents weren’t immediately informed. And when his mother Joanne informed staff her son was suicidal, after his first weekend visit home, there were no formal meetings to discuss the issue nor any real attempt to engage with them and keep them informed. However consultant psychiatrist at the Priory, Dr Hoyos refuted this point and said he was not informed of George’s worsening suicidal thoughts by his parents, only the issue of George’s medication making him worse.

George’s mum told the court her son seemed happy in the early days at the hospital but wasn’t happy about the anti-psychotic medication being resumed. She said her son told her he would sometimes spit out his medication so it was changed to a melt in the mouth tablets. The court heard that George had drawn pictures of scenes depicting his suicide.

She requested that Dr Hoyos reduce his medication but the court heard that he refused, believing it to be a crucial part of his treatment. He prescribed George anti-depressants at which point his suicidal tendencies worsened, however Dr Hoyos explained that there is no significant evidence that the particular anti-depressants George was prescribed caused suicidal tendencies.

George’s father told the court that when he returned home for a weekend he was “far from well” and when he visited him at the Priory his son looked “hideous” and thought his son was getting worse.

After dropping George off at the Priory on the Sunday after his first weekend visit, his mum was given permission to pick her son up on the Thursday and take him home for a second home visit where they had a busy and pleasant family evening ahead of his tragic end the following morning.

The court heard that Dr Hoyos did not keep regular written clinical notes, which is being looked into by the General Medical Council, but he said this did not affect patient care. He said that normal procedure after a patient’s home visit is for a nurse to find out how the visit went and report back to him. He said it was “important” that the family was engaged with the unit.

At the time of his death, the headteacher of Woodroffe School in Lyme Regis where George was a pupil paid tribute to the youngster describing him as “talented” and “hard-working”. On a Facebook page set up for his friends to express their grief for George, friends described him as a “sweet boy”, a “loving, talented young lad” and “an amazingly gifted and talented boy who was well loved”.

The inquest continues tomorrow, Tuesday, October 7.


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Coroner highly critical of care provided to 15 year old boy at Priory Hospital, Southampton

09 Oct 2014

Assistant Coroner, Lydia Brown, criticised the Priory Hospital, Southampton, and Consultant Psychiatrist Dr Carlos Hoyos, for the care provided to 15 year old George Werb, in June 2013, resulting in his death on 28 June 2013. She was also critical of mental health provision in the UK and especially the fact that some children are placed in units hours away from the family home. In recording a narrative verdict, the coroner noted that Dr Carlos Hoyos, the Consultant Psychiatrist in charge of George’s care made no clinical notes and had to rely on his recollections in giving evidence.
The coroner found that she was unable to place much reliance on such recollections and instead preferred the evidence of Mr and Mrs Werb, who had written down their concerns that George was suicidal following a period of home leave. Unfortunately, the parents’ concerns were not acted upon, and despite a nurse also recording that George was very suicidal on 24 June 2013, a decision was made to allow George on home leave on 27 June 2013 without an up to date risk assessment being carried out, and hours after he had been prescribed an anti-depressant, Fluoxetine, which has a known short term side effect of potentially increased suicidality. The coroner found that before home leave commenced, George was assessed as having no suicide risk.
The information used in this assessment was incomplete, inaccurate and did not reflect the actual situation. A member of staff had in fact suggested that the proforma risk assessment document for suicide risk be changed from “no” to “yes” prior to George departing on home leave, but such action was not taken. The coroner refuted any suggestion that George’s parents would have taken George home on 27 June 2013 had they been in possession of all the available information and noted that they had placed their trust in the psychiatric services. In commenting on Dr Hoyos’ assertion that he felt the parents did not trust the psychiatric services, she stated “frankly, who could blame them. The parents were doing their best to care for George; they had a right to expect the same of the services they entrusted their son to.” The coroner was unable to conclude that George had committed suicide as at the time of his death he was hearing voices which may have told him to take his own life.
George died at approximately 06:50 on 28 June 2013 when he calmly stepped out in front of a train near Seaton Junction in Devon, just 45 minutes from his family home. The coroner is calling for an inquiry by NHS England and the Department for Health following this inquest. The GMC are also investigating Dr Hoyos. Mark Bowman, the family’s solicitor commented on their behalf: “The findings that the information used to assess George’s suicide risk were incomplete, inaccurate and did not reflect the actual situation, is upsetting and we believe George would still be here had things been different. To lose our son of only 15 years, who had so much more to accomplish and experience is totally heart-breaking.”