Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate communication of SSRI suicide risk
The earlier warning
Samuel Morgan · 9 Dec 2020 · Colin Phillips, Swansea and Neath Port Talbot
“However, it has been suggested that the "Black Box Warning" (as developed by the Food and Drug Administration in the USA) would have a more 1 immediate impact and capture some patient's attention highlighting any risks.”
judiciary.uk/prevention-of-future-death-reports/samuel-morgan
What was promised
Stated action 1 · response to Samuel Morgan (9 Dec 2020) · stated timescale: none stated
“We have taken note of your suggestion that the”
What recurred
- 7 Jan 2025 · Thomas Kingston · Katy Skerrett · Identical hazard · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Samuel Morgan · 9 Dec 2020
“However, it has been suggested that the "Black Box Warning" (as developed by the Food and Drug Administration in the USA) would have a more 1 immediate impact and capture some patient's attention highlighting any risks.”
Later · Thomas Kingston · 7 Jan 2025
“Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications, and”
What happened next
No evidence found either way · stated action 1
“A black box warning is the FDA's most stringent warning for drugs and medical devices on the market. Black box warnings, or boxed warnings, alert the public and health care providers to serious side effects, such as injury or death. The FDA requires drug companies to add a warning label to medications that have a black box warning.”
Black Box Warnings - Fast-Tracked Drugs & Increased Use · drugwatch.com/fda/black-box-warnings
No evidence found does not mean the action did not happen.