Aaron Atkinson

Regulation 28 Report to Prevent Future Deaths 
Derby and Derbyshire Integrated Care Board Response  

Derby and Derbyshire Integrated Care Board (DDICB) would like to extend our sympathies to the 
family and friends of Aaron Atkinson. Please find below the ICBs response and future plans in 
regard to the Regulation 28 Report to Prevent Future Deaths. 

If there are any areas which you feel you would like more information or to discuss in person this 
will be arranged. 

Aaron was found deceased on the morning of 20 April 2023 at his home address. His death was 
completely unexpected. 

As his cause of death was not known a postmortem examination was conducted including 
toxicology. The pathologist’s opinion was that Aaron had died due to a seizure and positional 
asphyxia. 

Aaron’s mother was doubtful of the cause of death proposed and pressed for a second 
postmortem which was undertaken by a different pathologist. That pathologist considered that a 
more likely cause of death was cardiac arrhythmia caused by Aaron’s prescription of Risperidone 
(for behavioural regulation), and Ritalin (for ADHD – attention deficit hyperactivity disorder). 

On the court’s assessment of the evidence, applying the balance of probabilities, a probable 
medical cause of death cannot be determined. 

The court notes that Aaron’s medication reviews to check for any complications were conducted in 
line with local health guidelines. Aaron’s last review took place in November 2021, but Aaron did 
not attend subsequent reviews which were offered. 

The following report and action plan is in response to the matters of concern revealed through the 
course of the inquest as below. The concerns have been reviewed with actions to prevent future 
deaths captured in the action plan at the end of the report. This will be reviewed as per the 
timescales included within the report. 

Coroner concerns  

Whilst Aaron had annual GP reviews related to prescription of anti-psychotic medication 
(Risperidone, although the inquest heard that prescription of Ritalin was also a relevant factor, 
particularly in combination with Risperidone), to check for signs of adverse side effects and 
physical health complications, those reviews did not include ECGs (electrocardiograms) to check 
for signs of adverse effects on electrical activity of the heart. On the medical evidence before the 
inquest antipsychotic medication carries recognised risk of QT interval prolongation and lethal 
cardiac arrhythmias. It does not appear that the recognised risk of QT interval prolongation and 
lethal cardiac arrhythmias from long term prescription of antipsychotic medication is reflected in 
guidance to medical practitioners and prescribers, nationally or locally in terms of performing 
ECGs. The relevant NICE (National Institute for Clinical Excellence) guidance (web link below) refers 
to ECG testing under How should I monitor someone taking antipsychotics? and recommends 

 
 
 
 
  
  
  
  
 
 
 
 
 
 
 Electrocardiography (ECG) - after dose changes. Ideally, also annually. The local Derbyshire 
Integrated Care Board guidance (web link below) does not identify need for ECG to be included in 
annual monitoring in primary care unless if new medicines or changes to physical health have 
increased the risk of prolonged QTc arrange ECG. It appears there is lack of clarity and consistency 
for annual reviews to include ECGs where people are prescribed antipsychotic medication long 
term. Given the recognised risks explained at inquest then not providing annual ECGs for long 
term users of those medications appears to pose risk of death.  

NICE web link: https://cks.nice.org.uk/topics/bipolar-
disorder/prescribinginformation/antipsychotics/  

Derbyshire web link (DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC)):  

https://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by 
_BNF_chapter_prescribing_guidelines/BNF_chapter_4/Antipsychotics_Prescribing_and_Manage 
ment.pdf 

Derby and Derbyshire ICB Response  

Guideline review 

The Coroner identified a variance between the local Joint Area Prescribing Committee (JAPC) 
recommendation, which states: 

“If new medicines or changes to physical health have increased the risk of prolonged QTc arrange 
ECG” (page 9 of Derbyshire antipsychotic guidance), 

and the NICE Clinical Knowledge Summary (CKS) recommendation: 

“Electrocardiography (ECG) – after dose changes. Ideally, also annually.” 

It is also important to note that within the NICE CKS, the only medications where ECG monitoring 
is mandated are haloperidol, pimozide and sertindole (only available in UK on named patient basis 
– specialist use).  Furthermore, the Summary of Product Characteristics (SmPC), of these 
medications varies slightly from the NICE CKS: 

For Haloperidol  

'A baseline ECG is recommended before treatment. During therapy, the need for ECG monitoring 
for QTc interval prolongation and for ventricular arrhythmias must be assessed for all patients.'  

For Pimozide  

 'An ECG should be performed prior to initiation of treatment with pimozide, as well as periodically 
during treatment.' 

Sertindole – SmPC unavailable as unlicensed.  

For all other medications referenced, including Risperidone and methylphenidate, ECG monitoring 
is recommended as good clinical practice but is not mandatory. 

 
 
 
 
 
 
 
 
 Our considered position is that the ICB will amend the JAPC recommendation to align with the 
NICE CKS by advising ECG monitoring for all patients on antipsychotics after dose changes and 
ideally, also annually. This local change will be implemented while awaiting any future national 
guidance revisions from NICE, which would require country-wide adoption. 

Non engagement with monitoring  

Our local guideline will also be updated to reflect advice available on our JAPC guideline 
'prescribing in primary care', which reinforces the importance of regular engagement. This is of 
particular importance with respect to antipsychotic medications: 

ISSUING OF PRESCRIPTIONS 
'The patient’s condition is monitored appropriately, and prescriptions are not issued for patients 
who require further examination or assessment. This is particularly important in the case of 
medicines with potentially serious side-effects.' 

To further support patients and their carers, an overview of the Derbyshire Healthcare NHS 
Foundation Trusts 'local support services' will be added to the guideline, including a link to the 
webpage. Colleagues can use this link to signpost patients to appropriate support networks should 
they wish. This link will also be accessible on our medicines management website for ease of 
access.  

As part of the ICB's GP quality visits, data is included and discussed relating to the severe mental 
illness register/ reviews. The discussion at these visits includes a way of encouraging these 
patients to attend their reviews.  

We have reached out to the named GP, to support any actions they identify. Our aim is to share 
learning across the system to enable the scaling of improvements. In addition to the actions 
identified above, we are looking to identify any practice processes for non – engagement from 
patients.  

Actions to Address Concerns 

In light of these points, the ICB is undertaking the following steps: 

1.  Revision of Local Guidance 

o  Update Derbyshire antipsychotic prescribing guidance to add NICE CKS 

recommendations on annual ECGs for patients on antipsychotic therapy and after 
dose changes, matching NICE recommendations. 

2.  Await NICE response  

o  Await NICE's response to case and potential updates to national guidance 

regarding ECG monitoring standards for patients prescribed antipsychotics  

 
 
 
 
 
 3.  Shared learning 

o  Share lessons learned and guidance updates next steps with primary care 

clinicians and across relevant networks  

o  Share local support services link with colleagues across the system to raise 

awareness of support available to patients and carers that colleagues can signpost 
to.  

Please see below a timeline of proposed actions  

Action number 

Overview of DDICB actions  

Proposed completion date 

1a 

1b 

1c 

2a 

2b 

2c 

6/10/25 

6/10/25 

25/11/25 

INVESTIGATION AND SUPPORT 

Review investigation and 
lessons learnt/ actions 
identified by the practice. With 
support of the ICB primary care 
quality team and ICB patient 
safety team, identify support 
required. Identify relevant 
lessons learnt from GP quality 
visits  
Review response from NICE 
and acknowledge local updates 
if required. Plan further actions 
based on potential guidance 
changes.  
Update JAPC guideline 
'Antipsychotic Prescribing and 
Management for mental health 
conditions' and medicines 
management webpage, as 
identified above.   

REVIEW AND COMMUNICATIONS  

Extract shared learning from 
the practice and NICE 
responses and add lessons to 
be shared additionally to those 
raised above, into an incident 
report, ready to be shared with 
system colleagues. Learning 
report ratified through existing 
governance routes 
Collated learning to be shared 
through existing 
communications as identified 
above. 
At the Clinical Governance 
Leads meeting with general 
practice the Learning report 

6/11/25 

Following Derbyshire 
Prescribing Group (DPG) 
4/12/25.  

Following Derbyshire 
Prescribing Group (DPG) 
4/12/25. 

 
 will be discussed as part of the 
Patient safety standard agenda 
item.

2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

13 August 2025 

Mr Peter Nieto 

Senior Coroner for the coroner area of Derby and Derbyshire. 

Sent via email: 

Our reference: 

Dear Mr Nieto,    

Re: Regulation 28 Prevention of Future Deaths Report in respect of Aaron Atkinson 

I write in response to your regulation 28 report dated 30 June 2025 regarding the sad death 
of Aaron Atkinson. I would like to express my sincere condolences to Mr Atkinson’s family.   

We have reflected on the circumstances surrounding Mr Atkinson’s death and the concerns 
raised in your report. We note your concerns about the clarity and consistency for annual 
reviews to include ECGs where people are prescribed antipsychotic medication long term. 

Following receipt of your report, senior clinical advisors within the patient safety team here at 
NICE have reviewed the concerns raised, they have outlined the following.  

The link included in the report is to the Clinical Knowledge Summaries (CKS) prescribing 
information on antipsychotics: bipolar disorder - prescribing information - antipsychotics . It is 
important to note that this is not NICE guidance.   

The CKS are developed by an external company called Agilio Software and are designed to 
summarise the evidence on the treatment of specific health conditions. They use a variety of 
sources and may include NICE guidance, if there is any that is relevant, but they use many 
other sources too. We publish them on our website as a source of advice and information for 
health professionals working in primary care, but as noted above, they do not constitute 
NICE guidance.   

The CKS says (about antipsychotics generally): 

Regular monitoring may subsequently be done in primary care on specialist advice or 
depending on the person's care plan. This may include: 

•  Electrocardiography (ECG) - after dose changes. Ideally, also annually. 

o  Mandatory for haloperidol, pimozide, and sertindole; not required for 

antipsychotics with no effect, or a low-to-moderate effect on the QT interval 
and where there are no other risk factors for arrhythmia. 

 
 
 
 
 
 
 
 As part of this process, we have shared this report with Agilio Software for their awareness. 
The publishers of the CKS referred to have outlined that the recommendation on ECGs is 
taken from the Summary of Product Characteristics (SPC) information for each drug, 
provided below; 

Orap 4 mg tablets - Summary of Product Characteristics (SmPC) - (emc) | 6911  

Haloperidol Oral Solution BP 10 mg/5 ml - Summary of Product Characteristics (SmPC) - 
(emc) | 4521  

Serdolect 12 Mg Film-Coated Tablets -Summary 

For each of these, the advice is 'periodic monitoring'; Agilio have added the concept of 
'ideally annually' for these drugs as a pragmatic approach, as the manufacturers do not 
stipulate what they mean by 'periodic monitoring'.  

Agilio will be adding additional wording to clarify that the manufacturer has described 
risperidone as a medication which does not require further annual follow up ECG monitoring, 
as this drug is included in the category referred to in the CKS as 'not required for 
antipsychotics with no effect, or a low-to-moderate effect on the QT interval and where there 
are no other risk factors for arrhythmia.' Additional information will be added regarding drug 
interactions and prolongation on the QT interval in particular and the need for additional 
monitoring for these patients, almost certainly in secondary care.  

If further detail is required on the changes to the content of the CKS topic, Agilio Software 
can be contacted directly.   

NICE have also published a clinical guideline on bipolar disorder: assessment and 
management [CG185] which includes the following relevant recommendations:  

1.10.6 Before starting antipsychotic medication, offer the person an electrocardiogram 
(ECG) if:  

• it is specified in the drug's summary of product characteristics (SPC) or  

• a physical examination has identified a specific cardiovascular risk (such as  

hypertension) or  

• there is a family history of cardiovascular disease, a history of sudden  

collapse, or other cardiovascular risk factors such as cardiac arrhythmia or  

• the person is being admitted as an inpatient. [2014] 

For risperidone, there is no specific requirement for ECG monitoring in the SPC 

It says: 

QT prolongation has very rarely been reported postmarketing. As with other antipsychotics, 
caution should be exercised when risperidone is prescribed in patients with known 
cardiovascular disease, family history of QT prolongation, bradycardia, or electrolyte 
disturbances (hypokalaemia, hypomagnesaemia), as it may increase the risk of 

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 arrhythmogenic effects, and in concomitant use with medicines known to prolong the QT 
interval. 

There is no requirement for continued (e.g. annual) ECG monitoring with risperidone in the 
SPC, NICE guideline or the British National Formulary (BNF). The local guidelines say the 
following in annual monitoring: if new medicines or changes to physical health have 
increased the risk of prolonged QTc arrange ECG. 

The interaction in the BNF on risperidone and methylphenidate (Ritalin) relates to an 
increased risk of dyskinesia. 

In summary, we do not believe there is evidence for justification for annual ECGs for 
everyone prescribed long term antipsychotics. Prescribing information for risperidone does 
not include a requirement for continued ECG monitoring, however the publishers of the CKS 
will make some changes to the prescribing information on this topic to ensure it is clear 
where ECG monitoring is required.  

I hope this response has helped outline our role and the guidance that exists in this topic 
area. I would like to reiterate my sincere condolences to Mr Atkinson’s family.   

Yours sincerely, 

Chief Executive     

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