PFD report

Thomas Henry Robin Kingston · Prevention of Future Deaths report

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Issued 7 Jan 2025•Gloucestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
6

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised2

  1. Inadequate guidance on persisting with or switching SSRI medication when there is no benefit or adverse side effects
    Part of recurring concern: Unreliable guidance for medication continuation and discontinuation decisions
  2. Inadequate communication of suicide risks associated with SSRI medications
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Communicate updates on the presentation of suicidal-behaviour risks in antidepressant leaflets to healthcare professionals, patient groups and relevant voluntary organisations after the review and subsequent advice.

    Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 9 January 2025.
  2. Action

    Conduct an Expert Working Group review of how suicidal-behaviour risks are communicated in antidepressant leaflets, including engagement with patient charities and bereaved families.

    Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2025.
  3. Action

    Maintain GP Curriculum guidance on effective communication, risk assessment, suicide prevention, prescribing monitoring, and support for patients and carers.

    Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Medication side-effect and SSRI safety concerns are best addressed initially by the MHRA, with NICE considering action after collaborative work concludes.

    Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate guidance on persisting with or switching SSRI medication when there is no benefit or adverse side effects

Wider context from the report

“2. Whether the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has been achieved and/ or especially when any adverse side effects are being experienced. ”

Is this part of a recurring concern?

Yes — Unreliable guidance for medication continuation and discontinuation decisions.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate communication of suicide risks associated with SSRI medications

Wider context from the report

“1. Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications, ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Communicate updates on the presentation of suicidal-behaviour risks in antidepressant leaflets to healthcare professionals, patient groups and relevant voluntary organisations after the review and subsequent advice.

Verbatim wording from the response

“The considerations of the EWG are anticipated to complete in 2025. We will communicate to healthcare professionals, patient groups and relevant voluntary organisations any updates on how the risk of suicidal behaviours associated with antidepressants is presented in the antidepressant PILs following the conclusions of the EWG and subsequent CHM advice.”

Source location

Response from MHRA
Page 3 · response
Published 9 January 2025

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct an Expert Working Group review of how suicidal-behaviour risks are communicated in antidepressant leaflets, including engagement with patient charities and bereaved families.

Verbatim wording from the response

“In 2022, the MHRA sought the advice of the Commission on Human Medicines (CHM) on the need to convene an Expert Working Group (EWG) to review how the risk of suicidal behaviours is communicated in the patient leaflets to establish if this can be improved or if it would be more helpful for patients to receive this information in different formats within the regulatory framework. The first meeting of the EWG was held on 4 July 2024. Round table meetings involving patient charities and families of those bereaved by suicide will be held in March 2025. The membership and remit of the EWG can be found here Commission on Human Medicines - GOV.UK.”

Source location

Response from MHRA
Page 2 · response
Published 9 January 2025

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain GP Curriculum guidance on effective communication, risk assessment, suicide prevention, prescribing monitoring, and support for patients and carers.

Verbatim wording from the response

“General comments The GP Curriculum includes within its Clinical topic guides a section on Mental Health mentioning a role of the GP to specifically communicate effectively, professionally, and sensitively with patients, relatives and carers, recognising potential difficulties in communicating with people with mental health conditions and the importance of generating and maintaining rapport. There is a recognition to assess risk to make the patients safety a priority and offer patients relatives and carers advice and support regarding prevention, prescribing monitoring, and self-management of both mental and physical multimorbidity. The curriculum recognises the emerging issue of suicide prevention in mental health care.”

Source location

Response from Royal College of GPs
Page 1 · response
Published 9 January 2025

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide a Mental Health toolkit containing evidence-based guidance on medical and psychological treatments for depression and anxiety.

Verbatim wording from the response

“It is however usual to switch to a different class if there has not been a benefit or side effects and there are recommendations in the guidance on how to switch drugs safely between classes due to interactions and different bioavailability. It is also important to be clear on the indication for an SSRI and use of diagnostic criteria for both anxiety as well as depression, as the conditions can be separate or combined this can guide various treatment options. The RCGP also has a Mental Health toolkit which provides evidence-based guidelines for medical and psychological treatments for both depression and anxiety.”

Source location

Response from Royal College of GPs
Page 3 · response
Published 9 January 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Medication side-effect and SSRI safety concerns are best addressed initially by the MHRA, with NICE considering action after collaborative work concludes.

Verbatim wording from the response

“Given that the matters of concern relate to the side effects and safety of medication, specifically selective serotonin reuptake inhibitors (SSRIs), we believe that the key issues raised are best addressed in the first instance by the Medicines and Healthcare products Regulatory Agency (MHRA), and I note that your report has also been sent to them.”

Source location

Response from NICE
Page 1 · response
Published 9 January 2025

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing NICE guidance addresses suicide-risk warnings, treatment review and switching antidepressants when SSRIs are ineffective or cause side effects.

Verbatim wording from the response

“There are specific guidelines for Depression produced by NICE and most GPs shall follow NICE CKS (Clinical Knowledge Summaries). The guidance specifically covers the consideration of antidepressant drug treatment (using shared decision making to agree an appropriate treatment plan). The guidance includes advising that symptoms of anxiety, agitation, hopelessness, or suicidal ideas may increase when starting treatment, and advise when to seek urgent review. Advice is also given regarding review and switching antidepressant medication. This does mention considering a switch to a drug that the person has previously found helpful or prefers. In this case it is not clear whether there was a previous preference for a particular SSRI.”

Source location

Response from Royal College of GPs
Page 3 · response
Published 9 January 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Work collaboratively with the MHRA to address medication side-effect and SSRI safety concerns.

    Stated by National Institute for Health and Care ExcellenceStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2025.
  2. 2

    Develop and provide a Person-Centred Care toolkit supporting shared decision-making in general practice.

    Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Work collaboratively with the MHRA to address medication side-effect and SSRI safety concerns.

Verbatim wording from the response

“Therefore, we are currently working collaboratively with the MHRA on this issue. The outcome of that work will inform any action NICE may need to take in respect of its recommendations.”

Source location

Response from NICE
Page 1 · response
Published 9 January 2025

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and provide a Person-Centred Care toolkit supporting shared decision-making in general practice.

Verbatim wording from the response

“Shared Decision making 10 years ago, the RCGP recognised that GPs were leading the way in shared decision making and called for more guidance on shared decision making. The College has pioneered the development of a Person-Centred Care toolkit which includes support for shared decision making and in 2023 RCGP Scotland’s joint chair Chris Williams Commenting on the prescription of antidepressants by GPs, RCGP Scottland Joint Chair Dr Chris Williams said:”

Source location

Response from Royal College of GPs
Page 2 · response
Published 9 January 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
3/3

Data last updated 7 September 2026