Joshua Asprey · Prevention of Future Deaths report

On 18 June 2021 I commenced an investigation into the death of Joshua Fynn ASPREY aged 19. The investigation concluded at the end of the inquest on 15 March 2023.

I determined that the medical cause of Joshua’s death was:

1a Multiple injuries.

In box 3 of the record of inquest I recorded as follows:

Joshua Asprey died on 14th June 2021 from multiple injuries after deliberately jumping from a cliff

In box 4 of the Record of Inquest, I recorded a conclusion of:

SUICIDE

1. Joshua Asprey was 19 years old at the time of his death. He had a history of anxiety.

2. On 27 May 2021, Joshua attended a telephone consultation with his GP reporting that he was feeling depressed. He was commenced on sertraline, ████████

3. On 11 June 2021, Joshua attended a further telephone consultation with his GP and his dose of Sertraline was raised to ████████

4. The GP did not discuss with Joshua in either consultation any risk of suicidal ideation associated with commencing or increasing the dose of Sertraline. The GP relied on the British National Formulary (‘BNF’) which does not identify suicidal ideation as a risk of prescribing Sertraline.

5. Following the increase of his dose of Sertraline, Joshua began to have thoughts contemplating suicide.

6. On 14 June 2021, Joshua took his own life by deliberately jumping from a cliff ████████

7. Joshua left a suicide note on his computer in which he wrote: “The reason for my current state of thoughts and plans is probably due to suicidal thoughts caused by a side effect of changing from ████████ dosage of sertraline. However, while this is the trigger in the short term, these thoughts have existed and persisted within me for many years now and to blame solely the medication would be unjust.”

8. There was insufficient evidence on which to conclude that there was a causative link between the increased prescription of sertraline and Joshua’s death.

1. The evidence heard during the course of the inquest highlighted an inconsistency between the literature provided by the manufacturer of sertraline (the patient information leaflet (‘PIL’)) and the British National Formulary (‘BNF’) produced by the Royal Pharmaceutical Society (latest version: BNF 85, March 2023).

2. The PIL contains a list of “uncommon” side effect of suicidal behaviour, which includes the following in bold: “Cases of suicidal ideation and suicidal behaviours have been reported during sertraline therapy or early after treatment discontinuation (see section 2).”

3. The BNF relating to Depression (3.4, p395) and the use of Antidepressant Drugs states under the heading “Suicidal depression and antidepressant therapy” (p397): “The use of antidepressants has been linked with suicidal thoughts and behaviour; children young adults and patients with a history of suicidal behaviour and particularly suicidal behaviour are particularly at risk. Where necessary patients should be monitored for suicidal behaviour, self-harm or hostility, particularly at the beginning of treatment or if the dose is changed.”

4. The section of the BNF relating to SSRIs (p401) also identifies “suicidal behaviours” as a potential uncommon side-effect.

5. However, the section with respect to sertraline does not specifically identify suicidal tendencies at all, although it does identify “thinking abnormal” as an uncommon side effect (p.405).

6. I am concerned that there is a risk that a medical practitioner consulting the BNF with a view to determining dosage and treatment with Sertraline will be unaware of the potential risk of the onset of suicidal behaviour and/or would not consider it necessary to discuss that risk with the patient. The evidence heard at the inquest suggested that it would not be appropriate or practical for GPs to consider PILs before prescribing.

7. On the other hand, the PIL and BNF are intended for different purposes. It may be that the evidence of risk of suicidal ideation associated with Sertraline specifically (as opposed to SSRIs) is so low that it need not be referred to in the BNF, notwithstanding its inclusion in the PIL. Nevertheless, this is a matter of concern that would in my view benefit from further consideration.