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A coroner has warned there is a lack of clear and consistent guidance that annual health checks in general practice should include electrocardiograms for patients who have been prescribed an antipsychotic medicine in the long-term.

In his report on the death of 36-year-old Aaron Atkinson, who a pathologist concluded “likely” died as a result of cardiac arrhythmia caused by his prescription of Risperidone, the senior coroner for Derby and Derbyshire Peter Nieto said the risk of “lethal” cardiac arrhythmias from long-term antipsychotic use was also not “reflected in guidance to medical practitioners and prescribers nationally or locally in terms of performing ECGs”.

Cardiac arrhythmia 'likely' caused by prescription of Risperidone

An inquest heard Atkinson, who was found dead in his home in April 2023, died “completely” unexpectedly. A postmortem initially concluded he died from seizure and positional asphyxia but his mother was unconvinced and asked for a second postmortem which was carried out by a different pathologist.

That found cardiac arrhythmia caused by Atkinson’s prescription of Risperidone for behavioural regulation, as well as Ritalin for attention deficit hyperactivity disorder, was “a more likely cause of death”.

However, the inquest said that given the evidence and “the balance of probabilities”, a medical cause of death could not be determined.

Reviews did not include ECG to check for adverse effects on heart

“Aaron’s medication reviews to check for any complications were conducted in line with local health guidelines,” Nieto said in his report. “Aaron’s last review took place in November 2021 but he did not attend subsequent reviews which were offered.”

The inquest heard that although Atkinson had yearly GP reviews to check for side-effects and physical health “complications” as a result of him taking Risperidone, those reviews did not include an ECG to see if there were “adverse effects on the electrical activity of his heart”.

The inquest heard Ritalin was “a relevant factor” in his death “particularly in combination with Risperidone”.

In his report, Nieto said Derby and Derbyshire integrated care board guidance fails to “identify the need for ECG to be included in annual monitoring in primary care unless new medicines or changes to physical health have increased the risk” of QT interval prolongation – an abnormally long time the heart’s ventricles take to contract and relax.

Nieto sent a copy of his report to Derby and Derbyshire ICB chief executive Chris Clayton and gave the Board until August 25 to set out the steps it has taken or intends to take to address the situation.

Nieto also sent his report to the National Institute for Clinical Excellence chief executive Samantha Roberts. 

“The relevant NICE guidance refers to ECG testing under ‘How should I monitor someone taking antipsychotics?’ and recommends ‘electrocardiography – after dose changes. Ideally, also annually’,” Nieto said.