25 Nov 2025 Connor Nelson · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 2
Lack of a robust process for necessary referral and investigation of prolonged QTc syndrome View source Lack of medical staff understanding of the importance of identifying prolonged QTc syndrome View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Sherwood Forest Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Sherwood Forest Hospitals NHS Foundation Trust
Monitor incidents for prolonged-QT recognition trends and escalate concerns to the appropriate specialty.
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Sherwood Forest Hospitals NHS Foundation Trust
Issue the prolonged-QT clinical pathway to Trust staff through the intranet.
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Sherwood Forest Hospitals NHS Foundation Trust
Complete specialty and divisional sign-off of amendments to the prolonged-QT clinical pathway.
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Sherwood Forest Hospitals NHS Foundation Trust
Deliver teaching for medical staff on measuring QT intervals and relevant prolonged-QT cut-offs.
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Sherwood Forest Hospitals NHS Foundation Trust
Disseminate the QT-measurement teaching presentation to current medical consultants for wider educational use.
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Sherwood Forest Hospitals NHS Foundation Trust
Include QT-measurement learning and pathway signposting in specialty and divisional governance reports.
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Connor Nelson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Connor Nelson died at Kings Mill Hospital on 30 November 2024 from hypoxic ischaemic encephalopathy following a prolonged cardiac arrest on 10 November 2024. The report describes an undiagnosed congenital prolonged QT syndrome, a nine-minute delay in administering a necessary shock, and concerns about cardiac-arrest response and processes for identifying and investigating prolonged QTc syndrome.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a robust process for necessary referral and investigation of prolonged QTc syndrome
Wider context from the report “2. The lack of understanding by medical staff, of the importance of identifying prolonged QTc syndrome in patients attending KMH, with a lack of a robust process for ensuring necessary referral and investigation of the condition by the KMH Cardiology team .
” Source location Connor Nelson · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of medical staff understanding of the importance of identifying prolonged QTc syndrome
Wider context from the report “2. The lack of understanding by medical staff, of the importance of identifying prolonged QTc syndrome in patients attending KMH, with a lack of a robust process for ensuring necessary referral and investigation of the condition by the KMH Cardiology team.
” Source location Connor Nelson · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor incidents for prolonged-QT recognition trends and escalate concerns to the appropriate specialty.
Verbatim wording from the response “The governance support unit will continue to monitor incidents for trends and themes and ensure any concerns with incidents regarding recognition of Long QT are escalated to the appropriate specialty for review.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue the prolonged-QT clinical pathway to Trust staff through the intranet.
Verbatim wording from the response “During the patient safety incident investigation, it was identified that there was a knowledge gap regarding the management of Long QT and the Prolonged QT Interval Identified on ECG in Adults Pathway was developed which outlines the causes,” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete specialty and divisional sign-off of amendments to the prolonged-QT clinical pathway.
Verbatim wording from the response “During the inquest, the introduction of this new clinical document was duly noted. However, concerns were raised regarding its level of detail, particularly in relation to its suitability for staff without specialised experience in cardiology. Consequently, amendments have been implemented to address these concerns, as reflected in the draft pathway provided in Attachment 2. The draft pathway is progressing through the specialty and divisional sign off process with an anticipated completion date at the end of February 2026.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver teaching for medical staff on measuring QT intervals and relevant prolonged-QT cut-offs.
Verbatim wording from the response “With regard to the recognition of Long QT syndrome, it was noted that there were several missed opportunities to identify a prolonged QT interval on Connor’s ECGs as the QT did not appear to have been measured. On 22nd January 2025, a dedicated teaching session was conducted for medical staff at Grand Round, led by the cardiology team, which specifically addressed the methodology for measuring the QT interval and the relevant cut-off values. To support the ongoing sustainability of this training, the accompanying PowerPoint presentation has been disseminated to all current medical consultants, to enable regular educational sessions to be maintained for the broader medical team.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the QT-measurement teaching presentation to current medical consultants for wider educational use.
Verbatim wording from the response “With regard to the recognition of Long QT syndrome, it was noted that there were several missed opportunities to identify a prolonged QT interval on Connor’s ECGs as the QT did not appear to have been measured. On 22nd January 2025, a dedicated teaching session was conducted for medical staff at Grand Round, led by the cardiology team, which specifically addressed the methodology for measuring the QT interval and the relevant cut-off values. To support the ongoing sustainability of this training, the accompanying PowerPoint presentation has been disseminated to all current medical consultants, to enable regular educational sessions to be maintained for the broader medical team.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include QT-measurement learning and pathway signposting in specialty and divisional governance reports.
Verbatim wording from the response “In addition, across all specialty and divisional governance reports in February 2026 information on the importance of measuring QT when undertaking an ECG will be included as a hot topic for further trust wide learning and signposting to the Prolonged QT Interval Identified on ECG in Adults Pathway.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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30 Jun 2025 Aaron ATKINSON · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1
Lack of clear and consistent guidance on ECGs during annual monitoring of long-term antipsychotic medication View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
National Institute for Health and Care Excellence NHS Derby and Derbyshire Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
National Institute for Health and Care Excellence
Share the report with the Clinical Knowledge Summaries publisher to support awareness of the ECG-monitoring concern.
View source
NHS Derby and Derbyshire Integrated Care Board
Update local antipsychotic prescribing guidance to recommend ECG monitoring after dose changes and ideally annually.
View source
NHS Derby and Derbyshire Integrated Care Board
Review NICE’s response and implement any necessary local updates or further actions arising from changes to national ECG monitoring guidance.
View source
NHS Derby and Derbyshire Integrated Care Board
Share the ratified learning report and guidance updates with primary-care clinicians and relevant system networks through existing communications and governance meetings.
View source See 1 more action
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AI-generated summary
Aaron ATKINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Aaron Atkinson was found deceased at his home on 20 April 2023, and the death was unexpected. The inquest conclusion was unascertained, with medical evidence considering seizure and positional asphyxia, or cardiac arrhythmia associated with prescribed medication. The principal concern was that annual reviews for people taking long-term antipsychotic medication may not consistently include ECGs despite recognised risks of QT interval prolongation and lethal cardiac arrhythmias.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear and consistent guidance on ECGs during annual monitoring of long-term antipsychotic medication
Wider context from the report “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/prescribing-information/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_Management.pdf
” Source location Aaron ATKINSON · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the report with the Clinical Knowledge Summaries publisher to support awareness of the ECG-monitoring concern.
Verbatim wording from the response “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:” Source location 2025-0329 Response from National Institute for Health and Care Excellence
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update local antipsychotic prescribing guidance to recommend ECG monitoring after dose changes and ideally annually.
Verbatim wording from the response “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.” Source location 2025-0329- Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review NICE’s response and implement any necessary local updates or further actions arising from changes to national ECG monitoring guidance.
Verbatim wording from the response “2. Await NICE response” Source location 2025-0329- Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the ratified learning report and guidance updates with primary-care clinicians and relevant system networks through existing communications and governance meetings.
Verbatim wording from the response “3. Shared learning” Source location 2025-0329- Response from NHS Derby and Derbyshire Integrated Care Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agilio Software, the CKS publisher, is responsible for further changes and detailed information about CKS prescribing content.
Verbatim wording from the response “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:” Source location 2025-0329 Response from National Institute for Health and Care Excellence
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30 Nov 2016 Marjorie Cybil Bassendine · Prevention of Future Deaths report Surrey
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Concerns raised 3
Failure to undertake an ECG before commencing QT-prolonging medication View source Failure to undertake regular ECG monitoring during continuing treatment with multiple psychotropic medication View source Failure to recognise the QT-prolonging potential of multiple psychotropic medication View source
Linked responses
Medicines and Healthcare products Regulatory Agency Royal College of Psychiatrists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Royal College of Psychiatrists
Review continuing medical education initiatives to ensure comprehensive coverage of the medication-safety issue in College materials.
View source
Royal College of Psychiatrists
Publicise the medication-safety concerns to Royal College of Psychiatrists members and fellows.
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Royal College of Psychiatrists
Determine how best to raise the medication-safety concerns with old-age psychiatrists.
View source
Medicines and Healthcare products Regulatory Agency
Review the product information for olanzapine, mirtazapine and indapamide to assess QT-prolongation warnings.
View source See 1 more action
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AI-generated summary
Marjorie Cybil Bassendine · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Marjorie Cybil Bassendine, aged 98, suddenly collapsed while eating breakfast at her care home on 2 October 2015 and died despite resuscitation. The inquest recorded cardiac arrhythmia, long QT syndrome and therapeutic drug use as the medical cause of death. The principal concern was that multiple medications capable of prolonging the QT interval had been prescribed without assessment of her cardiac status, including an ECG, or regular ECG monitoring.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to undertake an ECG before commencing QT-prolonging medication
Wider context from the report “2. To undertake an Electrocardiogram (ECG) prior to commencing such medication .
” Source location Marjorie Cybil Bassendine · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to undertake regular ECG monitoring during continuing treatment with multiple psychotropic medication
Wider context from the report “3. To undertake regular ECG's to ensure long QT syndrome has not developed and to help plan continuing treatment .
” Source location Marjorie Cybil Bassendine · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise the QT-prolonging potential of multiple psychotropic medication
Wider context from the report “1. To recognise use of multiple psychotropic medication has the potential to prolong the QT interval .
” Source location Marjorie Cybil Bassendine · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review continuing medical education initiatives to ensure comprehensive coverage of the medication-safety issue in College materials.
Verbatim wording from the response “3. We will review our continuing medical education initiatives to ensure that this issue is comprehensively covered in RCPsych material;” Source location 2016-0424-Response-by-RCPSYCH
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publicise the medication-safety concerns to Royal College of Psychiatrists members and fellows.
Verbatim wording from the response “Actions planned by the Royal College of Psychiatrists:” Source location 2016-0424-Response-by-RCPSYCH
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Determine how best to raise the medication-safety concerns with old-age psychiatrists.
Verbatim wording from the response “Actions planned by the Royal College of Psychiatrists:” Source location 2016-0424-Response-by-RCPSYCH
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the product information for olanzapine, mirtazapine and indapamide to assess QT-prolongation warnings.
Verbatim wording from the response “We have reviewed the product information (Summary of Product Characteristics [SmPC] and Patient Information Leaflet) of olanzapine, mirtazapine and indapamide and are satisfied that all three contain appropriate warnings regarding the risk of QT prolongation, particularly when used with other medication that also causes QT prolongation. Details of the relevant warnings are included in Annex A.” Source location 2016-0424-Response-by-MHRA
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing product warnings appropriately address QT-prolongation risks, so no regulatory changes are currently proposed.
Verbatim wording from the response “We have reviewed the product information (Summary of Product Characteristics [SmPC] and Patient Information Leaflet) of olanzapine, mirtazapine and indapamide and are satisfied that all three contain appropriate warnings regarding the risk of QT prolongation, particularly when used with other medication that also causes QT prolongation. Details of the relevant warnings are included in Annex A.” Source location 2016-0424-Response-by-MHRA
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26 Oct 2015 Wayne Patrick O'NEILL · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to perform ECG traces for prisoners receiving the specified medication combination View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Herefordshire and Worcestershire Health and Care NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Herefordshire and Worcestershire Health and Care NHS Trust
Provide routine annual ECGs to patients prescribed antipsychotic medicines, including relevant interacting combinations.
View source
Herefordshire and Worcestershire Health and Care NHS Trust
Sample-audit annual ECG provision for all patients who should have received one.
View source
Herefordshire and Worcestershire Health and Care NHS Trust
Provide an additional ECG when a patient's antipsychotic medication is changed, regardless of the annual ECG date.
View source
Herefordshire and Worcestershire Health and Care NHS Trust
Book ECGs when antipsychotic treatment is initiated and provide new receptions taking antipsychotics with an ECG within one month of arrival.
View source
Herefordshire and Worcestershire Health and Care NHS Trust
Provide whole-nursing-team training to recognise medicines requiring ECG referral.
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AI-generated summary
Wayne Patrick O'NEILL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Wayne Patrick O'NEILL was a serving prisoner at HMP Long Lartin who collapsed in his cell and died on 2 January 2013. The inquest recorded respiratory failure, bronchospasm following ingestion of propranolol, and asthma as the medical cause of death. Concerns included the prescribing of propranolol despite asthma, the combination of psychotropic medicines with potential cardiac effects, and the failure to undertake an ECG before his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to perform ECG traces for prisoners receiving the specified medication combination
Wider context from the report “(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 clinician 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 ████████ a Cardiologist. He said there was a strong case for ECG traces to be performed on all 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 effects 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 .
” Source location Wayne Patrick O'NEILL · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide routine annual ECGs to patients prescribed antipsychotic medicines, including relevant interacting combinations.
Verbatim wording from the response “• 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.” Source location 2015-0444-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Sample-audit annual ECG provision for all patients who should have received one.
Verbatim wording from the response “• 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.” Source location 2015-0444-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide an additional ECG when a patient's antipsychotic medication is changed, regardless of the annual ECG date.
Verbatim wording from the response “• Patients who are prescribed anti-psychotic medication, whose medication is changed, will receive an ECG even if they have already received their annual ECG.” Source location 2015-0444-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Book ECGs when antipsychotic treatment is initiated and provide new receptions taking antipsychotics with an ECG within one month of arrival.
Verbatim wording from the response “• 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.” Source location 2015-0444-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide whole-nursing-team training to recognise medicines requiring ECG referral.
Verbatim wording from the response “• 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.” Source location 2015-0444-Response
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.