Gloucestershire senior coroner, Katy Skerrett, said in a Prevention of Future Deaths (PFD) report she was concerned to know “whether there is adequate communication of the risks of suicide” associated with SSRIs, and if guidance on persisting with the drugs, or switching to another type, was appropriate when a patient had adverse side-effects.

Katy Skerrett is the latest coroner to highlight concerns about SSRIs. Working with the Preventable Deaths Tracker research platform at King’s College London, The Times has found 40 PFD reports which reference the use of either citalopram or sertraline by patients who later died.

The reports identify a range of concerns including the failure to alert patients to the potential side-effects, breaches of prescribing guidelines, not reviewing patients and not keeping records of patients’ behavioural changes while on the medication.

In December 2020 a coroner in South Wales suggested citalopram should come with US-style “black box” warning after the suicide of Samuel Morgan, 25, from Swansea.

Samuel Morgan started taking citalopram a week before his death in January 2020. The coroner, Colin Phillips, reported: “Whilst the precise effect of this medication (citalopram) on Sam is unknown, it is clear that Sam had never self-harmed previously and his actions were completely out of character.”

Colin Phillips said that while the drug came with a patient information leaflet, a black box warning “would have a more immediate impact”. He added: “The simple and clear message in this specific case would be that there is an increased risk of suicidal thinking in young adults.”

The Medicines and Healthcare Products Regulatory Agency (MHRA) rejected the coroner’s suggestion saying the warnings in patient information leaflets had been reviewed and tested.

In May 2023 assistant coroner for East Sussex, Michael Spencer, issued a report following the suicide of Joshua Asprey, 19, who started taking sertraline 18 days before he took his own life in June 2021. His GP had increased the dosage three days before Asprey’s death.

The coroner expressed concern that the medicines guidebook, the British National Formulary, “does not identify suicidal ideation as a risk of prescribing sertraline”. He said that in two telephone consultations, Asprey’s GP “did not discuss any risk of suicidal ideation associated with commencing or increasing the dose of sertraline.”

In 2016 a coroner in Cambridgeshire expressed concerns about how a GP, on the advice of a nurse, had prescribed citalopram to Edward Mallen, 18, two weeks before he took his life.

In another case, 2015 Emma Bray, 25, killed herself 17 days after her dosage of sertraline had been increased. 

An assistant coroner for east London, Laura Johnson, noted in a PFD report in 2016: “Risks associated with the drug sertraline do not appear to have been communicated to Emma and her family.”

A psychiatry professor, David Healy, told the Thomas Kingston inquest that regulators “shied away” from setting out the suicide risk of taking the pills.

The MHRA said it kept SSRIs under constant review and added: “Following concerns raised by patients and families about how the risk of suicidal behaviours is communicated in the patient leaflets, we have established a new independent expert group to advise the Commission on Human Medicines, which provides expert advice to government ministers.”

Coroners have also repeatedly aired concerns about the easy availability of a deadly poison which has been linked to suicides.

Assistant coroner for Surrey, Anna Loxton, wrote about the substance, which The Times is not naming, after an inquest into the suicide of Hannah Aitken, 22.

Anna Loxton noted that there had been five prevention of future death reports sent to the Home Office about the poison since 2020, but no “active consideration” was being given to controlling access to it.  The poison remains unregulated in the UK, with no restrictions on buying it from abroad.

In her PFD the coroner urged the government to investigate the poison, saying it did not appear there was any consideration of regulating or monitoring it and that it was not even clear which department was responsible.

A Times investigation in 2023 revealed how the Canadian, Kenneth Law, was selling the lethal substance to suicidal people around the world. Law is now facing 14 counts of murder in Canada and his sales have been linked to 131 deaths worldwide, including 97 in Britain.

But concerns about the poison in the UK predate Law’s activities. In November 2020, a senior coroner wrote to to then health secretary, Matt Hancock, to warn that the poison was “easily and cheaply obtainable” on the internet “with no safeguards.”

The report, from Cumbria’s assistant coroner, mentioned another PFD, made two months before in West Yorkshire, after the suicide of Joe Nihill, 23, who had also taken the poison.

The substance is currently “reportable” under the Poisons Act, meaning sellers must report suspicious transactions, but is not regulated.

Anna Loxton said medical witnesses had told Aitken’s inquest the use of the poison for self-harm was increasing. None were aware of a central monitoring system able to record incidents of poisoning.

Her report has been sent to home secretary, Yvette Cooper, and Wes Streeting, the health secretary. Aitken died in September 2023 at her supported living accommodation for people with autism after taking the poison, which she had ordered online from abroad.

After her inquest, her father, Pete, said: “We have learnt that the risks associated with this poison have been known about for at least five years and that coroners have been repeatedly raising concerns about its dangers. Yet clearly, vulnerable adults like Hannah can still get access to it and use it to end their lives.”

A Home Office spokesman said: “Our thoughts are with the families and friends of Hannah Aitken and any other individuals who have sadly lost their life due to this substance.

“Retailers are required to report any attempted or suspicious transactions of poisons where the buyer may intend to cause harm to themselves or others. We are reviewing the Future Prevention of Deaths Report and will consider if further action is required.”