John Abrahams (Jack) · Prevention of Future Deaths report

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.

Jack Abrahams was 20 years old when he took his own life by means of self-ligature. I heard evidence that when Jack was 17 years old, he had received a six month course of Isotretinoin (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.

The Commission for Human Medicine (CHM) established an Isotretinoin 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 Isotretinoin 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.