John Abrahams

I am Catherine McKenna, Area Coroner for the Coroner area of Manchester North

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. J heard evidence that when Jack was 17 years old, he had received a six month course of lsotretinoin (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.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows: The Commission for Human Medicine (CHM) established an lsotretinoin 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 lsotretinion 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.

In my opinion action should be taken to prevent future deaths and  I believe  each of  you respectively have the power to take such action.