Open Letter to Office of H.M. Coroner, Sheffield.

For the sake of autism, dialogue, knowledge and life…



C.P. Dorries OBE, Office of H.M. Coroner.
Also for the attention of:
Sheffield Health and Social Care NHS Foundation Trust,
Dr. Helen Baker, Office of H.M. Coroner,
Dr. Alfredo Walker, Office of H.M. Coroner
Dr. A.R.W. Forrest, Royal Hallamshire Hospital, Sheffield
Dr. S. Morley, Royal Hallamshire Hospital, Sheffield
Danielle Carter, Fulwood House, Sheffield
Shelagh Bostock, Michael Carlisle Centre, Sheffield
Dr. Rodhri Huws, Eastglade Centre, Sheffield
Dr. Zaidi, Eastglade Centre, Sheffield
Shaun Holman, Eastglade Centre, Sheffield
Jaime Baite, Eastglade Centre, Sheffield
Dr. M. Fernandez, Michael Carlise Centre, Sheffield
Roger Marshall, Argyll House, Sheffield
John Heron, Argyll House, Sheffield
Ian Shaw, Argyll House, Sheffield
Dr. Lagundoye, Fitzwilliam Centre, Sheffield
Corporate Affairs Officer, Fulwood House, Sheffield
Phil Clay, Norfolk House, Sheffield
Dr. M. Al-Shabender, Norfolk House, Sheffield
Dr. N. Seivewright, Norfolk House, Sheffield


Dear Mr. Dorries,

Thank you for your letter dated 1st February 2018 regarding the inquest into my brother’s death in 2006 and for your detailed considerations, given the time that has passed. I also thank you for providing copies of letters and the comprehensive report from Sheffield Care Trust, something that they refused me a viewing of “due to the Limitation Act 1980” (their letter 8.1.18).  I found them all very enlightening.

Today is the 12th anniversary of Paul’s death. He was 18 months younger than me and we grew up together. I have decided to write to you on this day as part of my personal closure.  It was on what would’ve been Paul’s 50th birthday last year when I chose to open the autopsy report. (I was previously unaware that I was entitled to access it, nor was shown it by our parents, but until now I’ve had a sense of a question around my brother’s passing).  I chose to write this letter to you today for myself and it seems apt for another reason, that being twelve years is the maximum limit set by the government for a legal enquiry (under exceptional circumstances) into assumed negligence.

Your letter clarified matters regarding the question about Risperidone being a contributory factor, in that you draw the conclusion:

“On my understanding the Risperidone would not increase the quantity of alcohol found in your brother’s body but it might have been the case that respiratory depression from the large quantity of alcohol would have been worsened.” (Your letter, 1.2.18)

Your view matches exactly the basis of my own enquiry, you have confirmed exactly what I suspected and I am now satisfied as to why there was a lingering question surrounding the circumstances and ever since then, a sense of something unresolved.  In addition, I wanted to eventually ask the Sheffield Care Trust, particularly Dr. Fernandez (Michael Carlisle Centre) and Ian Shaw (Argyll House) what precautions were taken in the light of the known dangers of prescribing Risperidone for an alcoholic after seeing information on a public internet site:

“Severe Potential Hazard, High Plausibility.  Applies to: Alcoholism.
Severe respiratory depression and respiratory arrest may occur. Therapy with neuroleptic agents should be administered cautiously in patients who might be prone to acute alcohol intake.”
Retrieved from:

It is noted that in a letter to Fulwood House, Dr. M. Fernandez points out that in November 2005,

“It was encouraging to see that Paul could cope with the discipline of a detoxification programme”

Further, the 2006 report (by Roger Marshall, Mental Health Social Worker) which you kindly provided reflects a change in Paul’s behaviour after being prescribed Risperidone by Dr. Fernandez in 2005, especially from December 2005 when this was altered to administration by injection:

“On 8th February 2006 Ian Shaw (Community Mental Health Nurse) visited Paul. ..Ian noted Paul’s thought appeared less structured with incoherent speech – muttering to himself and unable to stay on the subject of discussion….. Ian administered Paul’s depot injection as prescribed…. Paul claimed to be drinking two bottles of sherry per day.”

“On 10th March 2006 Paul was sitting outside Argyll House when Ian Shaw (Community Mental Health Nurse) arrived at work. Paul was drinking sherry and smoking a roll-up cigarette…”  “Ian… gave Paul his depot injection as prescribed.”

Paul was dead two days later.

Therefore, I think it is reasonable to deduce that Risperidone given to Paul, while highly intoxicated with alcohol led to ‘severe respiratory depression and respiratory arrest’ and this should be listed as a contributory factor (along with 1a. Ethanol poisoning. 2. Methadone use), if not, then as the primary cause of Paul’s death.

I would therefore kindly request that you take into consideration these details and adjust the Report on Autopsy accordingly.

Further, your letter also states that because the amount of alcohol found in Paul’s blood was “well above the amount that would normally be regarded as the cause of death. It may therefore be that the pathologist would have regarded the Risperidone as irrelevant in those circumstances.”

To me it is very surprising to discover that your pathologist upon reading the police report mentioning Paul’s state and the injection of Risperidone the day before he died (along with assumed general knowledge of the dangerous combinations), still did not carry out the standard test.  Deeming these factors “irrelevant” (even with the additional trace of methadone found in his blood) gives serious cause for concern.

As I said, I was going to put my question around the warnings of prescribing of this drug for an alcoholic person to the Sheffield Care Trust team, Dr. Fernandez and Ian Shaw etc, but I will not be doing so now and instead they and their departments at the time will simply receive a copy of this letter, when I locate their current whereabouts.  I do not wish to address them directly, nor do I wish to hear from them. I might add that the words ‘care’ and trust’ in the name hold some irony for me but anyway, forgiveness and forbearance have their places.  Of course, it would be convenient to attribute blame in the circumstances, but I am only interested in the facts and we now have enough to move on with our lives, albeit robbed of Paul’s life.  There are massive failings inherent in our mental health systems (and society), driven largely by drug profiteers and their peddled myths in scientific cures, as is well known.

You might also be interested to know that there is some history of autism and alcoholism in Paul’s family. But there is no suggestion of autism in the reports.  One of the three uses for Risperidone is for ‘irritability from autism’ so the neurological link to psychosis for drug purposes has already been claimed, yet autism was never reportedly suspected by anyone in this large group of experts.

The pathology of autism is sketchy and to imagine introducing a chemical into the brain of any autistic person per se to somehow suppress irritability, is at best, questionable.  ‘Psychosis is typically defined as a difficulty with reality-checking, and autism and psychosis frequently co-occur. ‘Atypical’ psychosis has been recently reported to be more common in those with autism, and this may be defined as a pronounced change in personality or alterations in functioning.  Autism and psychosis additionally share phenomenological similarities: they are both linked to difficulties in understanding others (and may share sensory processing alterations as well). Shared issues may be in social network size, loneliness, social behaviours, and social skills difficulties; stigma and discrimination likely exacerbate these and contribute towards experienced distress.’ (Beattie, 2017)

Humanity has become so ridiculously infatuated by drugs and cures. It is likely there are already cases proving detrimental effects of Risperidone. I had some mental issues and upon enquiry received an autism diagnosis in 2014.  As time and knowledge increases, I hope that more people will be screened for it instead of, as in Paul’s case and many people’s cases, being shunted around services with multiple faces and viewpoints to contend with and multiple dangerous drugs to try from people working with these companies and little genuine care of the individual.  Signs are ignored or clinicians simply don’t know what to do when, for example, as it’s reported in the case notes, Paul was observed always avoiding talking about his family history, or that his behaviour improved when a friend stayed with him, or that his thinking and speech became more incoherent at the time of starting a course of Risperidone, which Paul himself stated he didn’t want… All of this comes on top of the public warning of the dangers that I have already cited.

Paul presented a picture of someone clearly deeply troubled in social domains.  The above demonstrates that the health system and our society is deeply broken.

At least autism diagnosis has improved a lot since 2006. Moreover, ‘Open Dialogue’ is a pioneering service originating in Finland in the 1980’s, where a small, core team of genuinely caring experts get personally involved in the whole mentally ill patient’s family using transparent and open discussions with the patient and family.  This method has produced an astonishing 85% success rate of rehabilitation and psychosis has virtually disappeared in one area in Western Lapland, where it is the primary treatment and drugs are only administered in a tiny fraction of cases where complementary to the dialogue approach.  The practice is spreading throughout Europe and the world, I’m happy to say.  It deserves so much more attention from everyone and anyone who might purport to care about people’s mental wellbeing.  May I suggest that you and your colleagues read up on it?

Kind regards,

Jonathan Drury








Ref: Beattie, L. (2017)

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