Concerns raised 1
Failure to take unwitnessed seizure activity into account in Emergency Department assessment View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Adrienne Caroline STUDHOLME · 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
Adrienne Caroline STUDHOLME died on 23 September 2023 at Royal Blackburn Hospital after readmission following a left nephrectomy, with a spontaneous splenic haemorrhage and rupture identified later that day and subsequent myocardial infarction. The report states that her death was contributed to by a delay in diagnosing and treating the splenic rupture. Concerns included inaccurate fluid-balance charts, seizure activity not being considered unless witnessed by staff, and the absence of procedures, standard operating practice, and training to ensure recent surgery was considered and communicated during emergency-department triage.
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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 take unwitnessed seizure activity into account in Emergency Department assessment
Wider context from the report “(2) Evidence was heard that seizure activity would not be taken into account in assessing a patient in the Emergency Department unless it was witnessed by a member of staff
” Source location Adrienne Caroline STUDHOLME · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern that unwitnessed seizure activity is not considered in Emergency Department assessment does not reflect current or historic practice.
Verbatim wording from the response “With respect to point 2, this concern appears to have arisen from a miscommunication of the evidence provided and reflects neither current nor historic practice within the Emergency Department. Having contacted the consultant who was giving evidence, the point they were trying to convey was that a history of seizures would not warrant immediate escalation to a doctor (either from triage or subsequently). An actively seizing patient would represent a potential medical emergency, or - were it to occur in the department - a potential deterioration in a patient’s condition and that this therefore would be immediately escalated when reported from any source.” Source location Response from East Lancashire NHS Trust
Open published response
2 Apr 2024 Andrew Ewin-Ripp · Prevention of Future Deaths report East London
View report summary
Concerns raised 3
Lack of guidance on contacting the secondary care team after recurrent seizures View source Lack of discharge guidance on maintaining medication compliance despite prolonged seizure freedom View source Lack of discharge guidance on notifying clinicians about recurrent seizures View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Andrew Ewin-Ripp · 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
Andrew Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.
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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 guidance on contacting the secondary care team after recurrent seizures
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures . There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of discharge guidance on maintaining medication compliance despite prolonged seizure freedom
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period ; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of discharge guidance on notifying clinicians about recurrent seizures
Wider context from the report “There are believed to be around 500-600 SUDEP deaths in the UK each year. SUDEP deaths are common in young adults. The waiting times for outpatient neurology appointments is in the region of 9 months for the trust concerned. The inquest heard from an independent expert that it is not unusual to have waiting times of more than 6 months for outpatient neurology appointments. In the context of these lengthy waiting times, the following matters were of particular concern:
(1) GP practices are not required to carry out annual reviews of epilepsy patients, as they are, for other chronic diseases. The independent consultant neurologist considered that annual reviews by general practitioners would provide an excellent safety net to prevent future SUDEP deaths. The reviews could incorporate checks on compliance with medication; reviews of any seizure activity and reminder of ways to reduce the risk of seizures.
(2) There is clear national guidance in relation to how quickly patients should be seen following a first seizure, but no clear guidance around the longer-term monitoring of patients with epilepsy. How soon after the last seizure is it safe to discharge a patient? There is no clear guidance on this.
(3) After discharge from the secondary care team, there was no clear guidance provided in relation to the importance of maintaining full compliance with medication even if seizure free for a very long period; the importance of notifying the GP and/or the secondary care team about the recurrence of any seizure activity or clear guidance on how best to make contact with the secondary care team in the event of recurrence of seizures. There was no system in place, or guidance, requiring practitioners to ensure that this essential information is passed to patients on discharge.
(4) There was no care pathway for incorporating urgent reviews in neurology clinics in response to patients reporting concerns, such as a return of seizures or not tolerating medication.
” Source location Andrew Ewin-Ripp · Prevention of Future Deaths report
Open source report
16 Jan 2024 Trevor Alan MONERVILLE · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 3
Lack of prison staff training in managing long-term health conditions on the wings View source Lack of individualized seizure care planning and monitoring View source Deficit in national policy for managing and supporting prisoners with epilepsy and seizures View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Trevor Alan MONERVILLE · 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
Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.
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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 prison staff training in managing long-term health conditions on the wings
Wider context from the report “c. There was a lack of training of prison staff in dealing with long term health conditions such as epilepsy on the wings. I understand there is a deficit in national policy within the prison service to manage and support prisoners with epilepsy and seizures.
” Source location Trevor Alan MONERVILLE · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of individualized seizure care planning and monitoring
Wider context from the report “a. Consideration should be given to the review of the treatment, monitoring and management of patients with a history of epilepsy or seizures by both the prison staff and healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the ACCT had closed on 10th March 2021, there was no formal mechanism of monitoring Trevor’s condition . Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy is designed to protect other prisoners, but not those who suffer from medical conditions as Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized or tailored to the prisoner’s clinical requirements .
” Source location Trevor Alan MONERVILLE · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Deficit in national policy for managing and supporting prisoners with epilepsy and seizures
Wider context from the report “c. There was a lack of training of prison staff in dealing with long term health conditions such as epilepsy on the wings. I understand there is a deficit in national policy within the prison service to manage and support prisoners with epilepsy and seizures.
” Source location Trevor Alan MONERVILLE · Prevention of Future Deaths report
Open source 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 Deliver First Aid at Work and Emergency First Aid training to identified prison staff, including responses to seizures.
Verbatim wording from the response “HMPPS undertake First Aid needs assessments to ensure that sufficient emergency aid response is available on each site. First Aid at Work and Emergency First Aid training courses are delivered to identified prison staff, which includes emergency response to both minor and major seizures.” Source location Response from HM Prison and Probation Service
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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 epilepsy reviews and agree individualized care plans with patients.
Verbatim wording from the response “Response: Oversight of patients with long term conditions is currently being carried out by the long term conditions nurse and primary care nurses, supported by the regional primary care lead and inclusive of prescribers where applicable. In order to ensure that patients with epilepsy are monitored and supported through a patient-centred approach, the long term conditions nurse has been completing reviews and agreeing a personal care plan with the patient that is specific to their individual needs. This is aligned with the wider work that has taken place on long term conditions management pathways.” Source location Response from Practice Plus Group
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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 Create and maintain a SystmOne care plan hub with epilepsy templates and review-template links.
Verbatim wording from the response “Practice Plus Group made it an organisational priority for 2023 to ensure that the use of personalised care plans is embedded throughout sites at which Practice Plus Group is the healthcare provider. Using the limited capacity in which Practice Plus Group can make changes to SystmOne, the electronic medical records system, a care plan hub has been created to support clinical staff in accessing appropriate templates. This includes a specific care plan to support management of epilepsy and a direct link to the epilepsy care plan has been added within the review template for epilepsy annual reviews. Staff received training on the use of the care planning hub on SystmOne via workshops, regular updates and in June 2023 staff received a care plan guide.” Source location Response from Practice Plus Group
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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 Train healthcare staff to use the care planning hub through workshops, updates and guidance.
Verbatim wording from the response “Practice Plus Group made it an organisational priority for 2023 to ensure that the use of personalised care plans is embedded throughout sites at which Practice Plus Group is the healthcare provider. Using the limited capacity in which Practice Plus Group can make changes to SystmOne, the electronic medical records system, a care plan hub has been created to support clinical staff in accessing appropriate templates. This includes a specific care plan to support management of epilepsy and a direct link to the epilepsy care plan has been added within the review template for epilepsy annual reviews. Staff received training on the use of the care planning hub on SystmOne via workshops, regular updates and in June 2023 staff received a care plan guide.” Source location Response from Practice Plus Group
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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 Use SystmOne recalls to schedule, monitor and allocate long-term-condition reviews.
Verbatim wording from the response “Care planning workshops for the healthcare teams at HMP Lewes were facilitated by the national and regional primary care leads. The SystmOne recall functionality is being utilised to ensure a systematic approach is adopted for long term condition reviews and that these are monitored and staff allocated to book patients into clinics when required. Healthcare staff working at HMP Lewes have also been provided with access to a training module ‘Epilepsy training for primary care nurses’. This training is there to provide support on identifying different types of seizures, treatment review etc.” Source location Response from Practice Plus Group
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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 samples of epilepsy care plans for quality improvement and alignment with national guidelines.
Verbatim wording from the response “Practice Plus Group amended the process for reporting on care plans approximately 18 months ago and have seen positive progress in the quantitative data. Over the last 3-4 months a process to review a small sample of these plans to support quality improvement and align with national guidelines has been started. As HMP Lewes is a remand site, the completion rate will always be variable whilst new patients await their initial long term condition review. On review for December 2023, 83% of patients with epilepsy at HMP Lewes now have a documented care plan. The team are striving to achieve 100%, however the data taken at the end of the month is reflective of the prison’s population at that point in time and new arrivals in the last few days/week who have not yet received a long term conditions review would affect this figure.” Source location Response from Practice Plus Group
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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 Audit and monitor long-term-condition care plans to maintain progress.
Verbatim wording from the response “The most recent inspection report from HMIP/CQC dated 23 February 2023 states “Patients with long-term conditions had timely reviews, and a new care plan hub made sure clinicians and patients jointly managed care, which was safe and well-coordinated”. We will continue to regularly audit and monitor the long term conditions care plans of patients at HMP Lewes to ensure progress is maintained.” Source location Response from Practice Plus Group
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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 Training prison staff to manage epilepsy and seizures is a matter for His Majesty’s Prison and Probation Service.
Verbatim wording from the response “Response: This concern is for His Majesty’s Prison and Probation Service to address. However, as always Practice Plus Group are committed to working collaboratively with our prison colleagues to support the safety and wellbeing of our patients and would fully support any prison led epilepsy awareness campaign for officers and wing staff.” Source location Response from Practice Plus Group
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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 Healthcare provider PPG is responsible for seizure care plans, diaries and long-term health management; prison staff facilitate its instructions.
Verbatim wording from the response “As was heard at the inquest, the creation of a seizure care plan and seizure diary, a clinical matter, falls within the responsibility of the healthcare provider at HMP Lewes, Practice Plus Group (PPG). It is within PPG’s remit to decide which prisoners are fit to be managed on a standard wing and, where a health condition such as epilepsy is identified, whether the severity of this means they should be located on the inpatient wing. HMPPS will facilitate a move to the inpatient unit where this is required.” Source location Response from HM Prison and Probation Service
Open published response
18 Sep 2023 Amarjit SINGH · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Lack of seizure-response training for prison staff View source Unavailability of guidance for prisoners responding to a cellmate’s fit View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amarjit SINGH · 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
Amarjit Singh, aged 41, was found dead in his cell at HMP Pentonville on the morning of 21 November 2021 after his cellmate reported that he had suffered a fit, but medical attention was not sought and the cell door remained locked. The inquest jury determined that he died from natural causes, contributed to by neglect. Outstanding concerns included a careless cell-sharing risk assessment and gaps in prison staff and prisoner guidance and first-aid understanding, including failures to recognise the need for CPR or distinguish unconsciousness from 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 Lack of seizure-response training for prison staff
Wider context from the report “2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023 , I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit. Apparently, this has already been implemented in HMP Brixton.
” Source location Amarjit SINGH · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of guidance for prisoners responding to a cellmate’s fit
Wider context from the report “2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023, I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit . Apparently, this has already been implemented in HMP Brixton.
” Source location Amarjit SINGH · 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 Schedule training for prison staff at HMP Pentonville on responding to fits.
Verbatim wording from the response “Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October, and prisoners are given instructions at their induction on how to report concerns regarding a cellmate and the need to ring the emergency cell bell in circumstances where their cellmate is unwell so that staff can ensure healthcare attend.” Source location Response from HM Prison and Probation Service
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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 Prison authorities, rather than healthcare, are responsible for addressing staff training and prisoner guidance on managing seizures and first aid.
Verbatim wording from the response “Only number 1 above relates to healthcare, and therefore PPG, so we do not propose to respond to points 2 and 3, which no doubt will be addressed by the Prison.” Source location Response from Practice Plus Group
Open published response
28 Mar 2023 Louis James Rogers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6
Failure to document general practice assessment of febrile seizures View source Failure to make timely referrals from general practice to secondary medical services for febrile seizures View source Lack of coordinated response across clinicians to febrile seizure presentations View source
Delays in referral for assessment and investigation of febrile seizures View source Failure to ensure febrile seizure diagnoses are supported by the child’s presentation View source Failure to follow escalation guidance for complex febrile seizures View source See 3 more concerns
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Louis James Rogers · 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
Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.
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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 document general practice assessment of febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken.
” Source location Louis James Rogers · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make timely referrals from general practice to secondary medical services for febrile seizures
Wider context from the report “4. General Practice -
At his mother’s request after the possibility of a further seizure, Louis was reviewed by his general practitioner on the 13th May 2021 following which Louis’s mother was reassured without a detailed history from Louis’s mother or a full neurological examination and in the absence of documentation in circumstances whereby it was acknowledged there was sufficient information at that time to refer Louis to secondary services for the management of children with febrile seizures. It would therefore be appropriate to consider providing robust national guidance and education to general practitioners to ensure appropriate history, examination, investigation are undertaken to allow timely referrals to secondary medical services to be undertaken .
” Source location Louis James Rogers · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of coordinated response across clinicians to febrile seizure presentations
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” Source location Louis James Rogers · 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 Delays in referral for assessment and investigation of febrile seizures
Wider context from the report “1. Management and investigation of Febrile Seizures
Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’. Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness.
” Source location Louis James Rogers · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure febrile seizure diagnoses are supported by the child’s presentation
Wider context from the report “5. Febrile Seizure Pathway
Evidence was heard that Louis was seen by a number of clinicians without a co-ordinated response to his presentation and that consideration should be given for all hospitals emergency departments and GP’s to be provided with a febrile seizure pathway as a checklist to ensure children are not given a diagnosis of a ‘febrile seizure when this is not supported by their presentation and for all consultations – including GP appointment and information from the paramedics is available for all clinicians to view to provide a holistic picture and to assist further management.
” Source location Louis James Rogers · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to follow escalation guidance for complex febrile seizures
Wider context from the report “3. Improvement to and highlighting of the JRCALC guidelines for paramedic management of seizures in children
JRCALC guidelines indicated paramedics should have conveyed Louis to hospital or contacted the GP and/or Out of Hours GP service following Louis’s second seizure on 11th February 2020, as the close proximity of two seizures indicated it was a ‘complex febrile seizure’ rather than a febrile seizure. This led to a lost opportunity to expeditiously trigger further investigation and/or a referral to either the ‘first seizure’ service or to a specialist paediatrician for further assessment and management. Evidence was heard that improving and highlighting JRCALC guidelines with additional teaching would prevent this happening again.
” Source location Louis James Rogers · 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 Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.
Verbatim wording from the response “As a result of your Report, we will also be asking colleagues from each of the seven NHS regions to share the learnings from this matter and the guidance available with their Integrated Care Boards for cascading to relevant healthcare professionals.” Source location Response from NHS England
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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 Replace the epilepsy guideline with updated recommendations on referral and information and support after a first seizure.
Verbatim wording from the response “We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of Louis’ death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6).” Source location Response from NICE
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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 the JRCALC guidance on convulsions in children.
Verbatim wording from the response “I can confirm that I have liaised with the Chair of the JRCALC committee and that a review of the convulsions in children guidance has been undertaken. The JRCALC guidelines are used regularly by ambulance clinicians in everyday practice. Having reviewed our guideline we agree that if our guideline had been followed, Louis should have either been conveyed to hospital on 11th February 2021 when he had a second seizure that day or he should have been referred to a GP.” Source location Response from Association of Ambulance
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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 Continue reviewing the convulsions guidance through regular clinical-guideline review activity.
Verbatim wording from the response “In summary, having reviewed our guidance related to convulsions in children, we do not believe that it needs improving at present. We will review it as part of our ongoing work to ensure that all our clinical guidelines are reviewed on a regular basis and kept as up to date as possible with any new clinical evidence that we become aware of.” Source location Response from Association of Ambulance
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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 Inform ambulance-service medical directors and lead paramedics about the death and ask them to review relevant JRCALC guidance and local pathways.
Verbatim wording from the response “We have taken an action to make all the medical directors and lead paramedics of UK ambulance services aware of the circumstances of Louis’ death and have asked them to review the JRCALC guidance and any local pathways or guidance in relation to decisions around conveying children after seizures. We have also reminded ambulance trusts of a best practice guidance document that was written, approved and disseminated by NASMeD to ambulance trusts in July 2021: “Conveyance of children by operational ambulance clinicians in face-to-face settings” (attached). This was developed as a result of a Health Services Investigation Branch (HSIB) recommendation issued to us in June 2019 in relation to a case of an undetected button and coin cell battery ingestion in a child.” Source location Response from Association of Ambulance
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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 Remind ambulance trusts about best-practice guidance on conveying children in face-to-face operational ambulance care.
Verbatim wording from the response “We have taken an action to make all the medical directors and lead paramedics of UK ambulance services aware of the circumstances of Louis’ death and have asked them to review the JRCALC guidance and any local pathways or guidance in relation to decisions around conveying children after seizures. We have also reminded ambulance trusts of a best practice guidance document that was written, approved and disseminated by NASMeD to ambulance trusts in July 2021: “Conveyance of children by operational ambulance clinicians in face-to-face settings” (attached). This was developed as a result of a Health Services Investigation Branch (HSIB) recommendation issued to us in June 2019 in relation to a case of an undetected button and coin cell battery ingestion in a child.” Source location Response from Association of Ambulance
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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 NICE is responsible for producing clinical guidance on the diagnosis, treatment and management of febrile seizures.
Verbatim wording from the response “The National Institute for Health and Care Excellence (NICE) are responsible for producing clinical guidance for health and care practitioners on the issue of febrile seizures. Their guidance on Epilepsies in children, young people and adults (NG127) covers the diagnosis, treatment and management, referral recommendations and information and support for the management of epilepsy and seizures in children:” Source location Response from NHS England
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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 national guidance is considered sufficient for managing febrile seizures.
Verbatim wording from the response “NHS England has been sighted on the response to your Report from NICE, who have advised that there is sufficient national guidance regarding the management of febrile seizures.” Source location Response from NHS England
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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 national guidance and the Clinical Knowledge Summary are considered sufficient to support timely assessment, investigation and referral for febrile seizures.
Verbatim wording from the response “We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of Louis’ death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6).” Source location Response from NICE
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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 RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.
Verbatim wording from the response “RCEM would be happy to work with NHS England / National Institute for Healthcare Excellence, Royal Colleges and other interested parties to help develop further evidence based or consensus guidance in this complex area of clinical practice. We are mindful that this would be a significant undertaking and that it would therefore not be appropriate for RCEM to take the lead on such a project.” Source location Response from Emergency Care Committee
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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 The convulsions-in-children guideline does not need improvement at present, subject to routine review and updating when new clinical evidence emerges.
Verbatim wording from the response “In summary, having reviewed our guidance related to convulsions in children, we do not believe that it needs improving at present. We will review it as part of our ongoing work to ensure that all our clinical guidelines are reviewed on a regular basis and kept as up to date as possible with any new clinical evidence that we become aware of.” Source location Response from Association of Ambulance
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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 AACE is the appropriate organisation to decide whether JRCALC guidelines for paramedic seizure management require updates.
Verbatim wording from the response “Regarding any updates to be made to JRCALC guidelines for paramedic management of seizures in children, I have been sighted on the response to your Report from the” Source location Response from NHS England
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17 Jan 2023 John Allen Martin HENDERSON · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to provide closer monitoring for prisoners with seizure activity View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Allen Martin HENDERSON · 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
John Allen Martin Henderson was found dead in his bunk at HMP Rochester on 27 May 2021. The inquest recorded natural causes, namely ischaemic heart disease, following a fatal haemorrhage into the wall of the left circumflex artery. Concerns included delayed medical investigations, the absence of a welfare check at the start of the day, and a lack of a clear process for sharing relevant medical information with front-line prison staff.
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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 provide closer monitoring for prisoners with seizure activity
Wider context from the report “During the course of evidence, I also established that John was not being monitored any more
closely than other prisoners due to his seizure activity . That was confirmed by ████████
████████ in the course of their evidence. They indicated to me that sometimes they
will be asked to monitor prisoners more closely but this had not been applied to John .
Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021.
” Source location John Allen Martin HENDERSON · 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 Implement Personal Management Plans to obtain consent, share relevant medical alerts and guidance, record required observations, and review at multidisciplinary prison meetings.
Verbatim wording from the response “Since this inquest, Oxleas NHS Foundation Trust has worked closely with HMPPS to introduce a Personal Management Plan (PMP) which provides a way of sharing information between healthcare staff and prison officers.” Source location Response from Oxleas Forensic and Offender Healthcare Services
Open published response
27 Apr 2022 Raphael Jeffery Gill · Prevention of Future Deaths report South London
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Concerns raised 1
Failure to recognise the combination of seizures and cocaine as a medical emergency View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Raphael Jeffery Gill · 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
Raphael Jeffery Gill was stopped by police, arrested for drug-related offences, and suffered multiple seizures, including seizures in police care and an ambulance. The inquest identified delays in ambulance response and hospital assessment, failure to recognise the combination of seizures and cocaine as a medical emergency, and omission or delay in carrying out a venous blood gas test. The medical cause of death was recorded as multiple seizures associated with an underlying seizure disorder, cocaine and prescribed medication.
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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 combination of seizures and cocaine as a medical emergency
Wider context from the report “(1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency , a fact expressly found in the jury’s conclusion.
(2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency.
” Source location Raphael Jeffery Gill · 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 PFD report with the JRCALC Chair for consideration of further review of guidance on cocaine use and seizure activity.
Verbatim wording from the response “Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines and is of the view that these contain a detailed set of guidelines for the management of patients who have used cocaine and seizure activity is specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow for consideration of further review of the guidance.” Source location Response from London Ambulance Service
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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 Produce and publish an internal clinical refresher for frontline clinicians on cocaine-related risks and red-flag presentations.
Verbatim wording from the response “In terms of the LAS, we will produce an internal clinical refresher for all frontline clinicians, which will be shared in our internal 'Clinical Update' publication around the risks associated with cocaine to continue highlighting the 'red flag' presentations in respect of patients who have used cocaine. This is planned to be published in early Autumn 2022.” Source location Response from London Ambulance Service
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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 JRCALC clinical guidelines already provide detailed guidance on cocaine use, including specifically addressing seizure activity.
Verbatim wording from the response “Whilst we note that there was no undue delay on the scene once the conveying ambulance had arrived, we are aware that your view is that the clinicians were unaware that seizures on the background of cocaine use may present a marked clinical concern. Our Consultant Paramedic has reviewed the guidance within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Guidelines and is of the view that these contain a detailed set of guidelines for the management of patients who have used cocaine and seizure activity is specifically detailed. Our Chief Medical Officer will share your PFD report with the Chair of the JRCALC to allow for consideration of further review of the guidance.” Source location Response from London Ambulance Service
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3 Jan 2020 James Thomas Wheeler · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Lack of authoritative guidance on monitoring people with refractory epilepsy View source Lack of guidance on the availability and use of assistive technology for monitoring people at high risk from seizures View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
James Thomas Wheeler · 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
James Thomas Wheeler, who had refractory epilepsy alongside cerebral palsy and severe learning disability, was found unresponsive at Cheddle Lodge on 22 January 2018 and died shortly afterwards. The inquest concluded that he died following a nocturnal epileptic seizure while unobserved and not actively monitored. Concerns included the lack of authoritative UK guidance on monitoring people with refractory epilepsy and assistive technology, failures to provide required annual Care Act Reviews, and insufficient resources for local authorities to fulfil those duties.
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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 authoritative guidance on monitoring people with refractory epilepsy
Wider context from the report “1. To Sir Andrew Dillon, Chief Executive, National Institute of Health and Care Excellence
The court heard that there is currently an absence of authoritative guidance in the United Kingdom as to the monitoring of people with refractory epilepsy, both in hospital and community care settings .
A particular feature of this case was the absence of guidance as to the availability and use of assistive technology in monitoring individuals thought to be at high risk as a result of seizures.
” Source location James Thomas Wheeler · 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 guidance on the availability and use of assistive technology for monitoring people at high risk from seizures
Wider context from the report “1. To Sir Andrew Dillon, Chief Executive, National Institute of Health and Care Excellence
The court heard that there is currently an absence of authoritative guidance in the United Kingdom as to the monitoring of people with refractory epilepsy, both in hospital and community care settings.
A particular feature of this case was the absence of guidance as to the availability and use of assistive technology in monitoring individuals thought to be at high risk as a result of seizures .
” Source location James Thomas Wheeler · 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 Pass the stated concerns about monitoring refractory epilepsy and assistive technology to the guideline committee to inform its work.
Verbatim wording from the response “I have considered the circumstances surrounding Mr Wheeler’s death, and your concern that there is no national guidance on how to monitor people with refractory epilepsy (both in hospital and community care settings), including the use of assistive technology for those thought to be at high risk of seizures.” Source location 2020-0001-Response-from-NICE-Redacted
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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 the epilepsy guideline by reviewing evidence on seizure-detection technologies, epilepsy-related mortality risk factors, and interventions reducing seizure-related mortality.
Verbatim wording from the response “This guideline (CG137) is currently in the early stages of being updated.” Source location 2020-0001-Response-from-NICE-Redacted
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22 Oct 2019 Mr Paul Mclean · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Failure to ask callers how long the patient has been fitting View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Paul Mclean · 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
Mr Paul Mclean died on 9 October 2018 after prolonged status epilepticus, following an emergency call to the Welsh Ambulance Service on 22 July 2018. The initial call was downgraded from code red to amber, resulting in an approximately 80-minute response instead of the anticipated 15–20 minutes; the jury found that the extended response contributed to prolonged status epilepticus and his subsequent death. The principal concerns related to seizure-call question scripting and categorisation, recognition of airway problems, and communication pathways between the ambulance service, prison healthcare operators, and hospital clinicians.
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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 ask callers how long the patient has been fitting
Wider context from the report “1. The adequacy/accuracy of the scripting of questions for seizure/fitting calls. In particular, and in relation to code 12D02 calls (post 19.6.19) the requirement for a healthcare professional to call back after 20 minutes of continuous fitting to trigger a call upgrade from Amber 1 to Red.
In an email from ████████ of 17.10.19 @ 07.11 and read to the court, it was confirmed that the question is not currently asked of the caller to WAST, how long has the patient been fitting?
This would appear to be a crucial piece of information in order to ascertain as accurately as possible, the known timing of the onset of the fit, for the purposes of determining when the 20minutes has elapsed. E.g. if it is known that the patient has already been fitting for 10 minutes, then the advice to call back should be in 10 minutes hence. If the fit has just commenced, then obviously, that advice can be for a 20 minute call back.
” Source location Mr Paul Mclean · Prevention of Future Deaths report
Open source report
6 Sep 2019 Millie Creasy · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3
Failure to consider neuroprotective strategies after prolonged seizure View source Lack of prescriptive clinical treatment guidance for children presenting with prolonged seizure View source Failure to maintain neurological observation after prolonged seizure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Millie Creasy · 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
Millie Creasy suffered a prolonged seizure at home on 31 July 2018, was discharged from hospital after limited neurological observations, and was readmitted after deteriorating. She subsequently suffered respiratory arrest caused by brain herniation from raised intracranial pressure, and brain stem death was confirmed on 5 August 2018. Concerns included the lack of continued neurological observations, the absence of consideration of neuroprotective strategies after a prolonged seizure, and whether earlier identification and treatment of raised intracranial pressure might have improved her chances of survival.
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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 consider neuroprotective strategies after prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours);
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust .
” Source location Millie Creasy · 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 prescriptive clinical treatment guidance for children presenting with prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours);
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust.
” Source location Millie Creasy · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain neurological observation after prolonged seizure
Wider context from the report “(1) Millie was admitted to the Luton & Dunstable Hospital on 31 July 2018 at 14.42 hours having suffered a prolonged seizure of approximately 30 minutes which paramedics described as decorticate. She was subsequently discharged at 20.40 hours for with an appointment for review the following day (regular neurological observations had ceased after 2 hours );
(2) Whilst my factual findings recognised that any earlier treatment for raised ICP may not have altered the outcome, and that a diagnosis of raised ICP or the risk of raised ICP is a clinical one, I was informed that it was not possible for the Luton & Dunstable NHS Trust to be more prescriptive in terms of clinical treatment in cases where a child presents with a history of prolonged seizure and that, in any event, “the Trust did not have stronger evidence that a longer period of observation would help as neuro-observations will only detect the late situation when cerebral oedema has reached the point of coning/tonsillar herniation when intervention is often not effective. Additional interventions would only occur when the process is advanced enough for clinical detection and the outcome is poor”;
(3) During the Inquest, I heard evidence from ████████, Paediatric Intensivist, at St Mary’s Hospital, London. Both the Pathologist and ████████ agreed that an prolonged seizure can cause a hypoxic brain injury that may not become clinically apparent for hours or even days. ████████ also explained that if Millie’s condition had been identified at the stage of ‘peri-herniation’, she would have received neuroprotective procedures which would have improved her chances of survival; I have since been provided with a copy of the Imperial College Healthcare NHS Trust Guideline (Drafted by ████████): Neuroprotection for the patient on the Paediatric Intensive Care Unit. The scope of the guideline is said to be multi-protection team working in any area of Paediatrics and states that: “Whenever a patient has suffered a neurological insult or is at risk of primary (cellular damage leading to cell death) or secondary neurological injury (further cellular and structural injury) neuroprotective strategies should be commenced. Clinical situations where this should be considered include the following:
Traumatic Brain Injury
Sepsis – prolonged hypotension
Sepsis – meningitis, encephalitis
Post-cardiac arrest
Any CNS insult – prolonged seizures
Metabolic derangements – sodium, glucose, ammonia
Liver failure – encephalopathy”;
(4) Although the evidence suggested Millie had suffered a prolonged seizure, there was no evidence to suggest the potential need for neuroprotective strategies was, in fact, considered by the Luton & Dunstable NHS Trust.
” Source location Millie Creasy · Prevention of Future Deaths report
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Includes controls specifically dedicated to seizure or epilepsy care, including assessment, escalation, referral, response training, care planning, monitoring, assistive technology and treatment.
