Wayne O’Neill
PFD Report
All Responded
Ref: 2015-0444
All 1 response received
· Deadline: 21 Dec 2015
Response Status
Responses
1 of 1
56-Day Deadline
21 Dec 2015
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
During the Course of inquest the evidence revealed Matters giving (ise (D concern In opinion Inere Is a risk Ihat future deaths will occur unless acticn is taken In the circumstanzes i I5 mY Slatutary duly Io repon to YoU MATTERS QF CONCERN ara a5 follows (11 Ihe evidence rovealed that Mr O'e Il had died ircm ona cftwo causes: either, as tha Jury Ibund he had Iaken propranolol Ilicitly which induced the broncho wpasm thai caused nis (espiratory lallure_ Ilts worlh nctng that Mr ONeill had prev cusly been prescribed propranalal and Evidencc wa3 givon al the inquest by & forensic psychiatrist that thie fact it was cortra Indicaled (given Mr ONells asinma) appcared "to have been Iost" t0 the prascrbing clnicians at the time Jury tne My The
The alternaive cauze 0f death was that Mr ONelll died acuio cardiac allvte induced by the combination of peychctropic med caton prescnbed Ia hlm including citalopram Olanzapine and amitriplyllne_ An alen had pevlously buen ralsud by Ihe Medicines Healncate Rejulatory Authorlly waming against Ihe prescrijing of thesa drugs in combination An attampt had been Made to teke Mr C'Ne |l off these drujs but subsequent cliricians had ra-introduced them Ili was not clear from tie evidence tnat when Mr ONeill was screened in reception following transfor HMP Birmingham lo HMP Long Larin Ihe sign ficance ol Inese combinabons 0 Medication was recognised Expert exidenca Ws heard durngthe cauze of inquest notably Cardiologist He sald there was a S cng case I ECG traces t bP paricmmcd on all pnsoners In recarpf of thls mMedication This would TEvaal whether there %as any FIolongatinn Df the QTinterval The evidence revealed thatan ECG trace had not been underaken during Ihe years tnat Mr O'Nelll was an Inmate al HMP Brmingham; A trace was arrangad at HMP Long Lartin but had nottaken place by Ine tme ol Mr 0 Nellrs dzath having cnly becn roquested asa maller &l rouilne Tha eviderce suggested that Ihe jeason why the ECG was requested was due t0 an elevated pulse rate detacted al the receotion acteen rather than recogniton of the potentially toxic effons Of Prescriped medication Evidenco was glvon that oblalning 3n ECG trace Is & slmply cheap and straight forward maler IL woulc seEM s4n5 bl accordingly Ior al tha prisoners in recelpt ol this combinatian of medication to undergo ECG trares &5 part of the raception screaning process, {21 {31 ACTION shouLD BE TAKEN In My apinan action shculd be taken to prevent future deatns and believe you and ycur Trust have the power tD take such action; have indicated about what YoU may feclto be a sensible way to proceed
The alternaive cauze 0f death was that Mr ONelll died acuio cardiac allvte induced by the combination of peychctropic med caton prescnbed Ia hlm including citalopram Olanzapine and amitriplyllne_ An alen had pevlously buen ralsud by Ihe Medicines Healncate Rejulatory Authorlly waming against Ihe prescrijing of thesa drugs in combination An attampt had been Made to teke Mr C'Ne |l off these drujs but subsequent cliricians had ra-introduced them Ili was not clear from tie evidence tnat when Mr ONeill was screened in reception following transfor HMP Birmingham lo HMP Long Larin Ihe sign ficance ol Inese combinabons 0 Medication was recognised Expert exidenca Ws heard durngthe cauze of inquest notably Cardiologist He sald there was a S cng case I ECG traces t bP paricmmcd on all pnsoners In recarpf of thls mMedication This would TEvaal whether there %as any FIolongatinn Df the QTinterval The evidence revealed thatan ECG trace had not been underaken during Ihe years tnat Mr O'Nelll was an Inmate al HMP Brmingham; A trace was arrangad at HMP Long Lartin but had nottaken place by Ine tme ol Mr 0 Nellrs dzath having cnly becn roquested asa maller &l rouilne Tha eviderce suggested that Ihe jeason why the ECG was requested was due t0 an elevated pulse rate detacted al the receotion acteen rather than recogniton of the potentially toxic effons Of Prescriped medication Evidenco was glvon that oblalning 3n ECG trace Is & slmply cheap and straight forward maler IL woulc seEM s4n5 bl accordingly Ior al tha prisoners in recelpt ol this combinatian of medication to undergo ECG trares &5 part of the raception screaning process, {21 {31 ACTION shouLD BE TAKEN In My apinan action shculd be taken to prevent future deatns and believe you and ycur Trust have the power tD take such action; have indicated about what YoU may feclto be a sensible way to proceed
Responses
Response received
View full response
Dear Si Re: Waxne Patrick Q Neilldeceased Regulation 28: Rcport to provont futuro dgaths Thank 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 il is worth mentioning that t0 Mr 0 Neills inquest tha team at HMP Long Lartin were alroady very aware of the issues related to the prescribing of anti-psychotic medication ard had taken steps to addre3s the need for ECGs wen using these medicines and in particular when using these medicines in cortain comhination: or in combination with other medicines that interact to extend the QT interval Therelore All patients prescribed any sirgle or mulliple anti psychotic medication(s} and when prescribed in combination with other medications (such as tricyclic anti-depressants erythromycin etc ) that have a propensity t0 increase Ihe OT interval wil Teceive routine annual ECG as part of their package of care (there is a 12 monthly physical heallh Ievlem uf mental health service uaers and the ECG @om; part of this arrangement); This is already in place and was in place prior to Mr O Neills inquest The Lead Pharmacist at HMP Long Lartin will sarple audit this by 31 January 2016 to ensure Ihat all people who should received an ECG have dona 80. Patients who are prescribed anti psychotic medication; whose medlication is changed, will receive an ECG even if have already received their annual ECG. Cantan' Chrs BRuddon Cnie] Execubie: Sarh Dugan well GX RECEIVED 790 ^ AM CORONFR Way you prior have they
AIl stalf who are prescribers of anti-psychotic medication will receive a copy of the regulation 28 report, copy of tnis response an copy pf a Phamacist presentation which oullines the Iska associated with oxtended 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 mceting to ensure appropriate exposure of clinicians to this area of concern All patients initiated on anti-psychotic medicines at HMP Lartin will receive an ECG booked at the time the prescription 13 made and all new receptions on anti- psychotic medications will receive an ECG within one month of arrival attha 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 notnecessarily by & Primary Care nurse Whilst the combination of psychotropic medication had criginally been prescribed al HMP Birminghami, Ihe Medicines Healthcare Regulatory Authority aler relating t2 the prescribing of certain medications been shared with all of our proscribers at HMP Long Lartin to reinlorce awareness of prescnbing combinations of such medication; hope the above gives you somie 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 0'Neill's family that we take the care and treatment of our patients very geriously- We are happy to answer any further enquiries You might nave only sent this to yourself and shall be obliged if you could kindly fonwward to Mrs ONeill; As the issue raised may be of wider interest have no objections [0 this Tesponse being shared with the Chief Coroner or for wider circulation:
AIl stalf who are prescribers of anti-psychotic medication will receive a copy of the regulation 28 report, copy of tnis response an copy pf a Phamacist presentation which oullines the Iska associated with oxtended 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 mceting to ensure appropriate exposure of clinicians to this area of concern All patients initiated on anti-psychotic medicines at HMP Lartin will receive an ECG booked at the time the prescription 13 made and all new receptions on anti- psychotic medications will receive an ECG within one month of arrival attha 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 notnecessarily by & Primary Care nurse Whilst the combination of psychotropic medication had criginally been prescribed al HMP Birminghami, Ihe Medicines Healthcare Regulatory Authority aler relating t2 the prescribing of certain medications been shared with all of our proscribers at HMP Long Lartin to reinlorce awareness of prescnbing combinations of such medication; hope the above gives you somie 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 0'Neill's family that we take the care and treatment of our patients very geriously- We are happy to answer any further enquiries You might nave only sent this to yourself and shall be obliged if you could kindly fonwward to Mrs ONeill; As the issue raised may be of wider interest have no objections [0 this Tesponse being shared with the Chief Coroner or for wider circulation:
Report Sections
Investigation and Inquest
On 2 January 2013 commenced an Investigalion inla Ine death of Wayne Patrck ONEILL then aged 34 Tha investgation concluced at tha end ofajury inquest on 22 Ociobar 2015_ The conclusion of the inquest was acciJertal the Medical cause %l death belng I(a} respiratory fallure, I(b) Broricho spasm following irgesting Frcpranolol; I(c} asthma
Circumstances of the Death
Mr O Neln was a serving prisoner at HMP Long Lartin He suffered a collapse in his cell from which he could rcl be rasuscilaled He dicd &n 2" January 2013 The recorded < madical cause Df death af Ia) rezpiratory failure 1b) broncho spagm following injestng propranolol I(c asinma
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Transfusion Committees and Tranexamic Acid - England
Infected Blood Inquiry
High-risk medication monitoring
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.