PFD report

Wayne Patrick O'NEILL · Prevention of Future Deaths report

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Issued 26 Oct 2015•Worcestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to account for asthma contraindications when prescribing propranolol
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Unsafe medication prescribing
  2. Failure to prevent reintroduction of psychotropic medications contraindicated in combination
    Part of recurring concern: Toxicity risks from excessive or combined medication use
  3. Failure to recognise the toxic significance of medication combinations during reception screening
    Part of recurring concern: Failure to identify clinically significant medication risksPart of recurring concern: Inadequate prison reception safeguards
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Provide routine annual ECGs to patients prescribed antipsychotic medicines, including relevant interacting combinations.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2015.
  2. Action

    Sample-audit annual ECG provision for all patients who should have received one.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2015.
  3. Action

    Provide whole-nursing-team training to recognise medicines requiring ECG referral.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2015.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to account for asthma contraindications when prescribing propranolol

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. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Unsafe medication prescribing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to prevent reintroduction of psychotropic medications contraindicated in 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. ”

Is this part of a recurring concern?

Yes — Toxicity risks from excessive or combined medication use.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to recognise the toxic significance of medication combinations during reception screening

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. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; Inadequate prison reception safeguards.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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. ”

Is this part of a recurring concern?

Yes — Failure to reliably detect and manage prolonged QTc syndrome.

Open source report

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

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
Page 1 · response
Published 26 October 2015

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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

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
Page 1 · response
Published 26 October 2015

Open published response

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

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
Page 2 · response
Published 26 October 2015

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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

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
Page 2 · response
Published 26 October 2015

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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

Share the medicines-regulatory alert on prescribing medication combinations with all HMP Long Lartin prescribers.

Verbatim wording from the response

“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.”

Source location

2015-0444-Response
Page 2 · response
Published 26 October 2015

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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

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
Page 1 · response
Published 26 October 2015

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Distribute the regulation 28 report, response and pharmacist presentation on extended-QT medication risks to all antipsychotic prescribers.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2015.
  2. 2

    Include antipsychotic medication and extended-QT risks in GP supervision and Mental Health MDT meetings.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2015.

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

Distribute the regulation 28 report, response and pharmacist presentation on extended-QT medication risks to all antipsychotic prescribers.

Verbatim wording from the response

“• 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).”

Source location

2015-0444-Response
Page 2 · response
Published 26 October 2015

Open published response

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

Include antipsychotic medication and extended-QT risks in GP supervision and Mental Health MDT meetings.

Verbatim wording from the response

“• 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.”

Source location

2015-0444-Response
Page 2 · response
Published 26 October 2015

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026