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Investigation and inquest
On 17 September 2024 I commenced an investigation into the death of Aaron ATKINSON aged 36. The investigation concluded at the end of the inquest on 29 May 2025. The conclusion of the inquest was: -
Unascertained
Circumstances of the death
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.
Coroner’s 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/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
Information checked against the published report and official responses