The 1995 Inquest

This is part 2 in a series on the sudden death of Christopher Coulter. Part one can be found here.

More than six years ago and just yesterday, I wrote outlining the events subsequent to the sudden and unexpected death of County Down fifteen year old Christopher Coulter. Christopher, as you will recall, was found dead on the morning of the 18th December, 1994. Ten days before, he was given a single ‘catch up’ vaccine offering protection against measles and rubella. Today, I will cover the findings of the inquest held in 1995.

Coroners and Inquests

(UK readers, you might want to skip this bit, you probably know all this already.)

An inquest is a fact-finding inquiry into the manner and circumstances of death presided over by a coroner, an independent judicial officer, a crown appointee, who has a duty to investigate deaths deemed to be sudden, unexpected or where violence, misadventure or negligence may be a factor. Coroners have the power to call and, if necessary, summons witnesses to provide oral evidence or written reports. The coroner can order an autopsy should they deem it necessary. It is not, however, within their remit to determine whether or not a specific crime has been committed although the finding of “unlawful killing” is one among of a number of verdicts they can reach. The most common are:

  • natural causes;

  • accident or misadventure;

  • dependent/non-dependent drug abuse;

  • disasters subject to public inquiry;

  • industrial disease;

  • lawful killing (e.g. self-defense);

  • unlawful killing;

  • suicide;

  • open verdict (insufficient evidence to reach any other verdict).

1995 Inquest Findings

Senior Coroner, John Leckey, presided over the first (so far only) inquest into Christopher Coulter’s death, finding that he had died of natural causes. Christopher had, it was recorded, died of asphyxia during a seizure resulting from myoclonic juvenile epilepsy (JME): according to Christopher’s parents neither he nor anyone in the family had a history of epilepsy.

JME is a relatively common form of epilepsy affecting, between one in 1,000-2,000 worldwide. Its onset may be sudden and usually in adolescence. It is not associated with head trauma or other preciptating assault or injury. Its features:

  • Generalized tonic-clonic seizures (whole body twitching/jerking);

  • Myoclonic (twitching) seizures;

  • Seizure activity commonly upon waking;

  • Seizures can be preceded by stress, fatigue, poor sleep and drug/alcohol use, flickering lights;

  • Less commonly: absence type seizures;

  • Lifelong but responds well to anti-seizure medications;

Though heritable, only about one third of people diagnosed with JME report a family history of epilepsy and research suggests mutations in GABRA1 and EFHC1 genes are believed to increase susceptibility to the condition.

Sudden onset in adolescence, seizures upon waking and an idiopathic profile make JME a good candidate for the cause of Christopher Coulter’s death. Sudden Unexpected Death in Epilepsy, SUDEP, accounts for around 40% of deaths of people with epilepsy and, indeed, a first seizure can be fatal.

The MR vaccination was not considered a precipitating factor in Christopher’s death despite reports that a second child at the same school, who had received the MR vaccine at the same time, had also experienced what is believed to be a first (but not fatal) seizure subsequently. Referring back to the timeline in yesterday’s piece, you will notice that, in January 1996, responding to a query from Professor (now Dame) Ingrid Allen of the Institute of Pathology at Queen’s College, Belfast, Dr David Salisbury, Director of Immunisations at the Department of Health, asserted no unusual incidence of “unexplained complications” associated with the batch of MR vaccine Christopher and his classmate received. You will also see from the same timeline that Christopher’s GP did not submit a Yellow Card notifying of a possible adverse reaction to the vaccine until February 1996, some six months after this inquest concluded. I have found no evidence that second child’s possible reaction was reported in a more timely manner.

Part 3

Grounds for a second inquest.

featured image: Gates of Hillsborough Castle, Wiki Commons.



  1. I think the mystery factor here is the possible involvement of the ubiquitous commensal virus HHV-6, on top of the measles and rubella viruses that were administered in the vaccine. A coroner’s inquest cannot possibly add any useful information. Only a neuropathologist who can study the degree of activation of the three viruses in question in Christopher’s brain can add any useful information. Legally, Christopher’s unfortunate death was due to misadventure, some conflicting factor in his own physical makeup that reacted poorly to the vaccination and resulted in seizures and his death. It is not even clear to me that the seizures were a proximate cause of death; HHV-6 has the capability of causing fatal encephalitiides once it is “riled up”. Fortunately, these are rare, but they do occur in children. I sort of agree with you that the case has not been sufficiently examined, but further Legal examination will lead nowhere. Only Neuropathological examination might help, and there are very few neuropathologists who have expertise with HHV-6, measles and rubella. Jeanne Bell in Edinburgh is one. Katie (I forget her last name – I will look it up) in Cork is another (she is or was President of the Irish Neuropathological Association. Leroy Sharer at Rutgers Medical School in Newark, NJ (near me) is another, and one with whom I have worked before. If there are any remaining pathological samples of Christopher’s brain, you might consider sending me a few. I have studied measles, HHV-6 and HIV-1 in brains of children and adults. Rubella would be new to me, but I developed a special technique that allows me to detect specific DNAs in formalin-fixed, paraffin-embedded brain sections which, along with immunocytochemistry, should be able to detect the culprit in Christopher’s brain. This kind of probing won’t be cheap; however, it may bring resolution.

  2. The name of the IRISH NEUROPATHOLOGIST is Catherine (Katy) Keohane, but she retired as Consultant Neuropathologist in Cork University Hospital in February 2012. I haven’t seen her in decades, but she is a very fine person and might be willing to help.

    1. I am in no way related to the Coulter family, though, with my Irish surname I can see how you may have thought so. My husband is from Dublin and we live in Wales.
      I’ve been following Christopher’s story for many years and I’m blogging about it now because I’m in awe of his mother’s tenacity, I don’t believe that the role of the vaccine was adequately explored (disclaimer: I am very, very provaccine) and the events that have unfolded since his untimely death serve to highlight how poor a vaccine injury compensation system we have here in the UK. This blog was busy a few years ago and I’m not sure anyone else’s story could’ve spurred me to resurrect the site.
      That being said, thanks again for your comments and a timely reminder to sort out introduction pages etc.

      1. I have to state that I thought you were Christopher’s mum, and the autism part of your moniker really turned me on. it is my hope that if you think about this incident long and hard enough, and read the two papers that I suggested in a previous reply, that ways to combat the incredibly elevated incidence of autism may be found. The connection between HHV-6, autism and MS is the key; HHV-6 is acquired in infancy where it causes roseola, a mild disease that soon goes away, but leaves in its trail a brain seeded with LOTS of HHV-6-infected oligodendrocytes in the brain. Fom that point on, any environmental factor that can enter the CNS, such as some vaccine viruses, can “rile up” HHV-6 and give rise to serious neurological dysfunctions. In my paper “The secret lives of HHV-6”, I suggest a four-part cocktail of drugs for fighting MS. The same cocktail, or even parts of it, might also help to lessen the risk of acquiring autism from the MMR vaccine. In particular, I think it possible that simply taking Airborne along with most vaccinations will lower the risk. Airborne has amazingly strong positive effects on the immune system, and that might be enough to overcome the inflammatory effects of the vaccine. Like you, I am in favor of childhood vaccinations, but I believe that they should not be given until the child is at least 3.5 years old. The connection between vaccines and autism is that if HHV-6 gets “riled up” just at the age when the neural circuits associated with socialization are forming, the virus undoes these circuits and the child’s brain winds up miswired because the new circuits that are constantly forming connect the wrong locations. In a nutshell, I believe that if childhood vaccinations, especially the MMR, were to be delayed until after the child is over 3.5 years of age, the incidence of autism would drop from 1:60 and go back to 1:10,000 like it was 25 years ago. The risk factor in doing this is, of course, that the incidence of measles, mumps and rubella will rise, and these are not trivial diseases like roseola. I think I may have corresponded with you before, many years ago, before I wrote my papers (there are actually three that consider the issues of the MMR and HHV-6). It is good that you are a blogger. I am not. Perhaps the world is ready for a new discussion of this old case from MY point of view. I am usually humble, but here I think I have special insight. Read those papers and you decide.

      2. All the credible evidence shows that the only way to reduce the risk of your child not being Autistic post vaccination is to have a child who is not Autistic pre vaccination.

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