Not Broken, Betrayed: How the System Killed 12-Year-Old London Gadd
Updated
London Izabella-Ryén Gadd was just 12 years old when she died. She was a bright, empathetic, and deeply loved young girl who locked arms with her mom when they walked together and felt everything more deeply than most. Looking back at her life, it is clear that London was not a broken child. When she struggled, as all girls do at her age, her mother, Charay, did what parents are instructed to do. She trusted the system. Yet, what the system failed to share was that the DSM codes attached to London’s name would falsely label her instead of listening to her, and that its profit-driven process would abruptly close the probe into her struggles before it was ever even opened.
London had a full life. She played soccer year-round, loved to read, drew constantly, treasured family trips, had a contagious laugh, and dreamed of flying for the Air Force when she grew up. At twelve years old, London had just reached the height where Charay could kiss her on the forehead without bending down. No parent should ever have to experience the road leading to that moment.
A few years earlier, in late 2021, during the isolation of the COVID lockdowns, which instantly drove society — including our youth — to a life online, London started biting her nails and often repeated the ends of her own sentences back to herself, a speech pattern that Charay described as stuttering. Wanting to cover all bases and mindful that London was managing life between two households during an isolating time and had recently been given a smartphone, Charay took her for a behavioral evaluation. London tested positive for anxiety and separation anxiety, and negative for depression, and no medication was prescribed. Remaining true to her instinct to find root causes rather than clinical fixes for her children, Charay got London a cat, and the nail biting and stuttering stopped. Charay regularly used this approach with London, sharing that it included vitamins, patience, and the belief that her daughter’s body was asking for something when struggles arose. Still, despite the cat calming down what was visible on the surface, social media had quietly become a constant fixture in London’s life.
By October 2023, after the school had found a note from London saying she would be “better off dead,” Charay chose Pine Rest Christian Mental Health Services for inpatient care, specifically because she felt that a faith-based facility would be less likely to push medication. Unfortunately, that wasn’t the case. Within twelve hours of admission, a Pine Rest psychiatrist recommended Prozac for London. Pointing to the vitamin regimen already documented in London’s chart, Charay repeatedly refused for three days. Pine Rest didn’t let up, telling Charay that London needed to be on medication before she could be released, an assertion she understood as a threat to keep London longer if she didn’t comply. During the push for Prozac, no black box warning was ever discussed with Charay. She finally agreed to a 5-milligram dose, which was recorded in a consent form that later surfaced bearing her signature on a line marked for verbal consent, a document Charay never saw or knowingly signed. A few days after returning home, London told her mom that she hated Prozac and didn’t feel like herself. Charay trusted her daughter and London stopped taking the medication.
For a while, things with London seemed more stable. But over the following months, Big Tech’s grip tightened, and London’s social media use escalated. By early 2024, ready to take action to hold Big Tech accountable for the harm it is inflicting on our young people, London and Charay contacted a law firm handling social media addiction cases against online platforms. While filling out paperwork, London described her relationship with social media as part of the intake process. In her own handwriting, she shared: “[It’s] all I think about. My mom asks me to get off, and less than 1-2 minutes, I’m sneaking back on.” That particular law firm failed to produce action, and Charay eventually found another.
Still, by this point and without Charay’s knowledge, online platforms had been feeding London self-harm and suicide content algorithmically for years. Clearly, London was trying to get help. But again, the system was not listening. With no legal relief in sight and London’s struggles deepening, London asked to return to Pine Rest and was readmitted in July 2024. When insurance denied continued coverage, London’s diagnosis was quietly revised from suicidal ideation to “no harm to self.” Bear in mind that her condition had not changed, but the insurance denial changed the record. And, plainly, the diagnosis switch followed. While her discharge was arranged, London remained at Pine Rest.
Before her release, the psychiatrist again pushed Prozac, telling Charay that London’s previous trial wasn’t given enough time. This language, Charay later learned, appeared in London’s chart attributed to Charay herself, in a paraphrase she said she never communicated. Putting her trust in what she had been told by the doctors at Pine Rest, Charay agreed to ten milligrams. Within a swift three days, while London was still at Pine Rest and while Charay was actively raising concerns, London’s Prozac dose was doubled to twenty milligrams without Charay’s consent. The chart’s record of the original consent runs a full paragraph. Yet, the record of the increase from ten to twenty milligrams simply states “guardian consent,” with no name, no date, and no time. Charay shared that her phone records prove no one called her to discuss raising the dosage. In other words, they raised London’s dosage from 10 mg to 20 mg without telling her mother.
But it gets worse. Unbeknownst to Charay, London was given injections of Zyprexa during that same stay at Pine Rest, an antipsychotic drug prescribed for psychosis. London had never been diagnosed with psychosis, and that condition, along with any exchange about the drug Zyprexa, was never communicated to Charay. In fact, Charay did not learn about the Zyprexa injections until April of 2026, when a forensic pharmacogenomic review she commissioned herself on London’s postmortem blood, revealed it. Charay then discovered that it was documented in Pine Rest’s own medical records and had been there the entire time. Not one single professional at the facility told her that her child had been injected with Zyprexa, and London’s records reflected no clinical justification for it. Charay also learned that the same postmortem testing that detected Zyprexa had identified genetic variants that impacted how London’s body metabolized the Prozac she had been prescribed. If these variants had been tested for before London was discharged, there would have been grounds to reconsider the Prozac prescription entirely. Indeed, pharmacogenomic testing for exactly this purpose has existed since 2006. Yet, no one at Pine Rest ordered it to make sure it was safe for London.
In the end, London was sent home from Pine Rest on 20 milligrams of a drug that her own body was unable to metabolize properly— without a follow-up appointment, without a clarified black box warning, and without her mother knowing the full dose she was taking. The FDA’s own guidance flags the first weeks of SSRI treatment in adolescents as being the highest-risk window for suicidality. Despite this, Pine Rest had no monitoring plan in place covering that time, and no one told Charay she needed to create one herself. Equally as significant, there was no discussion about the Zyprexa that had been injected into London’s body.
Importantly, Charay later learned that prescribing information for Prozac differs around the world. Numerous international medication documents include pharmacogenomic data along with a clearer acknowledgment of metabolic differences in pediatric patients. In London’s case, that information is the difference between life and death, yet materials in the United States don’t emphasize it. Parents in other countries receive more comprehensive warnings than Charay did under our country’s arguably broken, profit-driven healthcare system.
Twenty-one days after being discharged from Pine Rest, on the evening of July 30, 2024, London reached out to four friends, telling them what she planned to do. Not one of them told an adult. Not one called for help. In the early hours of the following morning, Wednesday, July 31, London sent a series of text messages to her counselor—the same counselor who had encouraged Charay to agree to the Prozac weeks earlier. At 1:19 am, London texted: “Hey. Please help me. I’m sorry, can we talk? Please.” The counselor saw the messages and replied at 2:47 am, asking “Hey there — are you awake?” and telling London she was headed back to bed but would be up around 7 am if London still wanted to talk. At 11:30 am, London replied that she couldn’t call because she was with her grandparents. The counselor never followed up. No one called Charay and no wellness check was made. London would be dead in less than 15 hours later.
At some point during this time, London had managed to access a locked medicine cabinet in her mother’s room, leaving untouched two large bottles of ibuprofen sitting in plain sight at the front — the same drug she had once told a professional at Pine Rest that she had been warned could kill her. Instead, she took what was in the back, ingesting approximately 40 bupropion (Wellbutrin) pills, 18 aspirin tablets, and unknown amounts of azithromycin and penicillin. The fact that London bypassed the ibuprofen is significant because it indicates she was not trying to kill herself. That evening, after taking the pills, London began complaining of stomach pain and eventually told Charay what she had done. On the way to the car, London vomited most of what she had taken in the driveway, crying that she was sorry, begging her mother to understand she had only meant to hurt her stomach, not end her life. They walked into the hospital trusting they were in the right place. Nothing could be further from the truth.
Because in reality, London was not only let down by caregivers at Pine Rest. She was also let down by the ER staff at Memorial Healthcare in Owosso, who asked the family to sit in the waiting room upon arrival. At the time, Charay remembers thinking that being directed to the ER waiting room must mean the situation wasn’t as serious as she feared. Once in triage, London told staff repeatedly that she had not been trying to kill herself; she only wanted to hurt her stomach. Despite London’s own words clarifying that she did not want to kill herself, the medical records later reviewed by Charay told a different story, documenting that London said she wanted to kill herself. This is unacceptable.
Adding to the chaos at the hospital, ER staff gave London Zofran to stop her nausea, which also stopped the vomiting that had already expelled most of the pills she had taken. Charay asked them to pump London’s stomach, only to be told that was the “old school” way. She also asked for activated charcoal and was told by hospital staff that they weren’t sure if they had any. Charay later learned that no one had bothered to verify if that was the case. An ambulance arrived to transfer London to a larger facility in Lansing, but it sat outside, idle, for roughly 90 minutes while staff waited for a callback from Poison Control that never came. As they waited, London began seizing. She was intubated and given fentanyl, a drug Charay was later told carries serious toxicity risk in combination with the pills London had ingested. Sadly, London coded and could not be brought back. She was pronounced dead at 2:39 am on August 1, 2024.
The ER staff involved no longer work at that hospital.
In a matter of hours, Charay’s worst nightmare had become reality. The healthcare system in the United States failed London Gadd. When it comes to caring for our children, we assume warnings will be clearly explained, Charay said. We assume risks will be monitored, and we assume that if our child reaches out for help, someone will call the parents. Describing her reality, Charay shared:
“I am paying a life sentence without my daughter, and still there is no true accountability. I lost London, and I also lost the illusion that something is automatically safe just because it is FDA approved, called standard care, or handed to families under the promise of trust. Too often, what families are told is “science” becomes pseudoscience when labels replace investigation, risks are minimized, and no one is required to prove they looked at the whole child.”
Following London’s death, Charay has drafted legislation that she calls London’s Law, which is a proposed amendment to Michigan’s public health code that would require clinicians to document at least eight to twelve weeks of non-drug intervention before prescribing a psychiatric medication to a minor. London’s Law also mandates pharmacogenomic testing before any prescription is written and requires written informed consent that discloses the FDA’s black box warning in plain language. It also prohibits discharge driven by insurance denial and requires follow-up evaluations within 7 days of any new prescription or dose change. Likewise, it demands that social media platforms give parents real-time visibility into algorithmic content recommendations, preserve that data for ten years, and grants surviving parents full access to a minor’s account after death. Every provision in London’s Law maps back to safeguards that weren’t there for London.
London’s Law is personal to Charay and here’s why: a forensic review of London’s accounts after her death found self-harm and suicide content delivered algorithmically regardless of what she searched — even something as innocent as alligator skin boots. The review also found accounts and email addresses for London that Charay never knew existed, despite nightly phone checks, screen timers, and strict household rules.
Today, Charay is working with UnScripted Minds, a growing non-profit focused on root-cause approaches to mental health and is part of ongoing litigation against the platforms targeting our children. A bellwether jury recently found Meta and Google negligent. Her parent network watched the House pass federal child safety legislation (KIDS Act) in late June, stripped of the accountability provision they had spent years fighting for. Disappointed, Charay said that Big Tech moved fast on that one.
“Most people pick their battles,” Charay said, “Unfortunately, this one picked me.” To date, she has contacted roughly 70 attorneys regarding the hospital and psychiatric facility. Michigan’s wrongful death damages cap has led nearly all of them to decline, despite at least one calling her case clear-cut before turning it down. Presently, Charay has opened an estate in London’s name, a legal mechanism that extends the statute of limitations as she continues to search for counsel willing to take the case.
As noted above, Charay describes side effects of psychiatric medications differently than most doctors do. She calls them the body’s own signal, proof that something foreign doesn’t belong. Given all we know about the human body, coupled with how Big Pharma profits from our children, that assessment makes perfect sense.
Charay put it plainly, “London paid the price for a system that labels first and investigates last.” Indeed, London was not a broken child. She was a clinical trial for a broken system. Charay added:
“One child is too many. My daughter was not a statistic, not content, not a diagnosis, and not a risk to be managed. She was London. She was 12. She was loved. She should still be here.”