Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0444, written 26 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Oct 2015 |
|---|---|
| Reference | 2015-0444 |
| Deceased | Wayne O’Neill |
| Coroner | Andrew Cox |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Herefordshire and Worcestershire Health and Care NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Worcestershire Health and Care NHS Trust 3 CORONER lam Andrew James Cox, Assistant Coroner, for the coroner area of Worcestershire CORONER'S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, INVESTIGATION and INQUEST On 2 January 2013 | commenced an investigation into the death of Wayne Patrick O'NEILL then aged 34. The investigation concluded at the end of a jury inquest on 22 October 2015. The conclusion of the inquest was accidental the medical cause of death being 1(a) respiratory failure, 1(b) Broncho spasm following ingesting propranolol, 1(c) asthma . 4 | CIRCUMSTANCES OF THE DEATH Mr O'Neill was a serving prisoner at HMP Long Lartin. He suffered a collapse in his cell from which he could not be resuscitated. He died on 2” January 2013. The Jury recorded a medical cause of death of :- 1(a) respiratory failure 1(b) broncho spasm following ingesting propranolol 1(c ) asthma 5 | CORONER'S CONCERNS 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 MATTERS OF CONCERN are as follows, — (1) the evidence revealed that Mr O'Neill had died from one of two causes: either, as the jury found, he had taken propranolol! illicitly which induced the broncho spasm that caused his respiratory failure. It is worth noting that Mr O'Neill had previously been prescribed propranolol and evidence was given at the inquest by a forensic psychiatrist that the fact it was contra indicated (given Mr O'Neill's asthma) appeared "to have been lost" to the prescribing clinicians at the time. The alternative cause of death was that Mr O'Neill died from acute cardiac failure induced by the combination of psychotropic medication prescribed to him including citalopram, Olanzapine and amitriptyline. An alert had previously been raised by the Medicines Healthcare Regulatory Authority warning against the prescribing of these drugs in combination. An attempt had been made to take Mr O'Neill off these drugs but subsequent Clinicians had re-introduced them, It was not clear from the evidence that when Mr O'Neill was screened in reception following his transfer from HMP Birmingham to HMP Long Lartin the significance of these combinations of medication was recognised. Expert evidence was heard during the cause of the inquest notably from EEE 2 Cardiologist He said there was a strong case for ECG traces to be performed on ail prisoners in receipt of this medication, This would reveal whether there was any prolongation of the QT interval, The evidence revealed that an ECG trace had not been undertaken during the years that Mr O'Neill was an inmate at HMP Birmingham, A trace was arranged at HMP Long Lartin but had not taken place by the time of Mr O'Neill's death having only been requested as a matter of routine. The evidence suggested that the reason why the ECG was requested was due to an elevated pulse rate detected at the reception screen rather than recognition of the potentially toxic efforts of the prescribed medication. Evidence was given that obtaining an ECG trace is a simply, cheap and straight forward matter. It would seem sensible, accordingly for all the prisoners in receipt of this combination of medication to undergo ECG traces as part of the reception screening process. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your Trust have the power to take such action, | have indicated about what you may feel to be a sensible way to proceed. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely on or before 21" December 2015, |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed COPIES and PUBLICATION | have se my report to the Chief Coroner and to the following Interested Persons — | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. AJ Cox 26” day of October 2015 H M Assistant Coroner
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
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STRICTLY PRIVATE & CONFIDENTIAL “
Mr AM Cox
HM Assistant Coroner
Worcestershire Coroner's Court
The Civic
Martins Way
Stourport on Severn
Worcestershire
DY13 8UN
Dear Sir
Re: Wayne Patrick O’Neill deceased
Requlation 28: 0 vi h
Thank you for your letter and the enclosed regulation 28 report to prevent future deaths. |
hope that the following is helpful to you and is of some comfort to the family of Mr O'Neill.
Before dealing with the substance of your report it is worth mentioning that prior to Mr
O'Neill's inquest the team at HMP Long Lartin were already very aware of the issues
related to the prescribing of anti-psychotic medication and had taken steps to address the
need for ECGs when using these medicines and in particular when using these medicines
in certain combinations or in combination with other medicines that interact to extend the
QT interval.
Therefore:
¢ All patients prescribed any single or multiple anti-psychotic medication(s) and when
prescribed in combination with other medications (such as tricyclic anti-depressants,
erythromycin etc.) that have a propensity to increase the QT interval, will receive a
routine, annual ECG as part of their package of care (there is a 12 monthly physical
health review of mental health service users and the ECG forms part of this
arrangement). This is already in place and was in place prior to Mr O'Neill's inquest.
The Lead Pharmacist at HMP Long Lartin will sample audit this by 31 January 2016 to
ensure that all people who should have received an ECG have done so.
e Patients who are prescribed anti-psychotic medication, whose medication is changed,
will receive an ECG even if they have already received their annual ECG.
Chaiman: Chris Burdon
Chief Executive: Sarah Dugan
e All staff who are prescribers of anti-psychotic medication will receive a copy of the
regulation 28 report, a copy of this response and a copy of a Pharmacist presentation
which outlines the risks associated with extended QT intervals associated with
particular medicines and groups of medicines (we are happy to share this presentation
with you if you wish),
« The issue of anti-psychotic medication and extended QT intervals will be included in
the HMP Long Lartin GP supervision session and the Mental Health MDT meeting to
ensure appropriate exposure of clinicians to this area of concern.
« All patients initiated on anti-psychotic medicines at HMP Long Lartin will receive an
ECG booked at the time the prescription is made and all new receptions on anti-
psychotic medications will receive an ECG within one month of arrival at the prison.
¢ Training will be provided to the whole Nursing team with regard to recognizing
medicines that should indicate a referral for an ECG. These medicines might readily be
recognized by a Mental Health Nurse but not necessarily by a Primary Care nurse.
Whilst the combination of psychotropic medication had originally been prescribed at HMP
Birmingham, the Medicines Healthcare Regulatory Authority alert relating to the
prescribing of certain medications, has been shared with all of our prescribers at HMP
Long Lartin to reinforce awareness of prescribing combinations of such medication.
| hope the above gives you some reassurance that we have considered the regulation 28
letter carefully and to some extent we have ‘gone beyond’ the original issue of medication
interactions to consider the broader use of anti-psychotic medication with other groups or
even in isolation. We hope that this will reassure you and also Mr O'Neill's family that we
take the care and treatment of our patients very seriously. We are happy to answer any
further enquiries you might have.
| have only sent this to yourself and shall be obliged if you could kindly forward to Mrs
O'Neill. As the issue raised may be of wider interest | have no objections to this response
being shared with the Chief Coroner or for wider circulation.
Yours faithfully
Chief Executive
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