Recurring concern

Unreliable seizure care and management

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First reported 10 Jan 2018•Latest report 10 Oct 2025

Definition

What this concern includes

Includes controls specifically dedicated to seizure or epilepsy care, including assessment, escalation, referral, response training, care planning, monitoring, assistive technology and treatment.

Not included

Generic neurological care where seizure risk or management is not identified
Unrelated referral, monitoring or emergency-response failures
Case-specific seizure outcomes without an identified continuing control deficiency

Reports: 13
Individual concerns: 27
Date range: 2018–2025
Stated actions: 22

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service2

National Institute for Health and Care Excellence2

NHS England2

Practice Plus Group2

Royal College of General Practitioners2

Airedale NHS Foundation Trust1

Bedfordshire Hospitals NHS Foundation Trust1

College of Policing1

Community Disability Nurse1

Department of Health and Social Care1

East Lancashire Hospitals NHS Trust1

Independent Futures1

Joint Royal Colleges Ambulance Liaison Committee1

London Ambulance Service NHS Trust1

Luton and Dunstable University Hospital1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

12 Apr2019
West Sussex
Concerns raised1
1. Insufficient training on atypical seizure and post-seizure behaviour
This report raised 6 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.
Actions described in response 1
1. Action
  Include an epilepsy video in initial officer training and refresh it during refresher training every three years.
  Stated by Sussex PoliceStated completed
Respondent positions 3
1. Position
  Changes to nationally agreed police training packages require approval through national policing bodies rather than unilateral force action.
  Stated by Sussex PoliceRedirects responsibility
1. Position
  Basic first-aid training provides officers with knowledge and skills suitable for their policing role.
  Stated by Sussex PoliceExisting arrangements considered sufficient
2. Position
  Officers cannot reasonably be expected to possess medical professionals’ knowledge because attempting untrained interventions could pose excessive risks.
  Stated by Sussex PoliceUnable to act
AI-generated summary

Duncan Tomlin · 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

Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure behaviour.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient training on atypical seizure and post-seizure behaviour
Wider context from the report
“Understanding aspects of Epilepsy and Seizures 5. The training material which has been provided to me on behalf of Sussex Police covers many aspects of epilepsy and seizure that were explored during the inquest. The training material indicates that if it is available to the trainer, participants will be shown a video which informs the viewer of the way in which a person may present post seizure, namely confused, vulnerable, perceiving aggression from others and at risk of lashing out due to misunderstanding. I have also been provided with a copy of a training manual provided by Epilepsy Action which was sent to ACPO in 2011. Aspects of the evidence from the family in this inquest were entirely consistent with the less common presentations of a person in an atypical or post seizure state. Although epilepsy was not found to be causative in the death in this Inquest, in another situation with a similar set of circumstances, the reactions of a person suffering an atypical seizure or in a post seizure state, could be misconstrued as violence and resistance were officers not to appreciate that fact that their presentation may be part of a medical condition and restraint in such circumstances could have inherent and fatal risks. It is therefore of importance that training extends beyond the two more well known types of seizure and that post seizure behaviour is also understood in general terms. ”
Source location
Duncan Tomlin · Prevention of Future Deaths report
Page 4 · concerns
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
Include an epilepsy video in initial officer training and refresh it during refresher training every three years.

Verbatim wording from the response
“In relation to epilepsy in particular, there is a video which is included in the initial officer training course and is refreshed every 3 years in the refresher training. Sussex Police are considering hosting a link to that video on their internal website for all officers to be able to view.”

Source location
2019-0135-Response-by-Sussex-Police
Page 3 · response
Published 14 June 2019
Open published response
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
Changes to nationally agreed police training packages require approval through national policing bodies rather than unilateral force action.

Verbatim wording from the response
“We are currently delivering nationally agreed training packages and any alteration to these should be agreed nationally with approval of all parties. The benefit in delivering training packages (for all mandatory training, not just Personal Safety Training) is they are consistent across the UK, all police officers are trained in the most current, relevant and up to date thinking which is designed using the latest research and learning from all Forces. We are aware this is currently being reviewed by NPCC and any alterations passed onto Forces in order for them to include in their training. It would be expected these alterations would be completed by the end of 2020.”

Source location
2019-0135-Response-by-Sussex-Police
Page 2 · response
Published 14 June 2019
Open published response
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
Basic first-aid training provides officers with knowledge and skills suitable for their policing role.

Verbatim wording from the response
“Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time”

Source location
2019-0135-Response-by-Sussex-Police
Page 3 · response
Published 14 June 2019
Open published response
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
Officers cannot reasonably be expected to possess medical professionals’ knowledge because attempting untrained interventions could pose excessive risks.

Verbatim wording from the response
“Police officers are not trained to the level of medical practitioners. All police officers have basic first aid training (First Aid – Module 2 of the College of Policing curriculum which includes conducting CPR and managing a casualty who is convulsing) which gives them the knowledge and skills suitable for their role. It is the expectation that they recognise signs and symptoms of a wide variety of medical conditions. It is unrealistic to expect officers to have the knowledge of medical professionals, as the risks posed to themselves and others in trying to take action in which they are not trained is too great. Officers will carry out a dynamic risk assessment of any risk posed by a violent individual – whether the violence is caused by a medical condition or otherwise – and make a decision based on that risk assessment at that time”

Source location
2019-0135-Response-by-Sussex-Police
Page 3 · response
Published 14 June 2019
Open published response
30 Jul2018
West Yorkshire (Western)
Concerns raised1
1. Failure of care-home referral procedures for patients suffering seizures after recently sustained head trauma
This report raised 1 other concern. 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.
Actions described in response 2
1. Action
  Introduce and implement a Falls Protocol specifying procedures, observations, neuro-observations, escalation, emergency calls and post-hospital monitoring after resident falls.
  Stated by Riverview Nursing HomeStated completed
2. Action
  Provide training to all staff on completing the Falls Protocol.
  Stated by Riverview Nursing HomeStated completed
AI-generated summary

Stanford Shirley Bell · 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

Stanford Shirley Bell, who had dementia, fell at Riverview Nursing Home on 22 February 2018 and later died on 2 March 2018 after suffering seizures and an acute on chronic subdural haematoma. Concerns included the absence of hospital discharge papers and written neurological-observation recommendations, and delayed referral from the care home after seizures following head trauma.

Read the report on judiciary.uk
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 of care-home referral procedures for patients suffering seizures after recently sustained head trauma
Wider context from the report
“For Riverview Care home to review procedures at the care home with respect to referral to hospital of patients suffering from seizures after a recently sustained head trauma. ”
Source location
Stanford Shirley Bell · Prevention of Future Deaths report
Page 2 · concerns
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
Introduce and implement a Falls Protocol specifying procedures, observations, neuro-observations, escalation, emergency calls and post-hospital monitoring after resident falls.

Verbatim wording from the response
“In responding to your Regulation 28 request we have however taken a more direct ‘Lessons Learnt’ approach and additional measures have now been introduced with a specific ‘Falls Protocol’ including specific procedures to be followed for any resident fall (including falls which may result in head injury). The lesson learnt was that we could be, and will be, much more pro-active in our response to any resident fall.”

Source location
Stanford-Bell-Response
Page 1 · response
Published 30 July 2018
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 training to all staff on completing the Falls Protocol.

Verbatim wording from the response
“Training has been provided for all staff in completing the Falls Protocol however the protocol is written in a way to direct staff completing it in a step by step process. In response to your request for a timetable for action, the new protocol was introduced and went live at Riverview Nursing Home on 15th August 2018 (as a final draft awaiting external validation as we believed it offered a safer and improved response to resident falls). The Protocol was fully (externally) validated on 23rd August 2018.”

Source location
Stanford-Bell-Response
Page 2 · response
Published 30 July 2018
Open published response
10 Jan2018
Staffordshire South
Concerns raised2
1. Failure to seek medical assistance following seizures
2. Use of a seizure policy not specific to the resident
This report raised 11 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.
Respondent positions 1
1. Position
  The absence of a resident-specific seizure policy did not indicate inadequate care because no seizure history was disclosed and general epilepsy procedures were followed.
  Stated by Southwinds LimitedDisputes the concern
AI-generated summary

John Keith Edwards · 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 Keith Edwards, aged 64, was admitted to a care home for respite and subsequently suffered falls, seizures, reduced mobility, pressure sores and a rapid decline before dying in a nursing home on 19 December 2016. Concerns included inadequate care-home policies and care, failures to seek medical assistance and recognise deterioration, poor record-keeping, and inappropriate placement for his complex needs.

Read the report on judiciary.uk
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 seek medical assistance following seizures
Wider context from the report
“(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident. (4) Care Home staff failed to seek medical assistance following seizures. (5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home. (6) Care records were retrospectively filled in. (7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done. (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP. (9) Non patient specific dressings were used on pressure sores. (10) A non-patient specific mattress was used on his bed. (11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition. ”
Source location
John Keith Edwards · Prevention of Future Deaths report
Page 2 · concerns
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
Use of a seizure policy not specific to the resident
Wider context from the report
“(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident. (4) Care Home staff failed to seek medical assistance following seizures. (5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home. (6) Care records were retrospectively filled in. (7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done. (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP. (9) Non patient specific dressings were used on pressure sores. (10) A non-patient specific mattress was used on his bed. (11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition. ”
Source location
John Keith Edwards · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 absence of a resident-specific seizure policy did not indicate inadequate care because no seizure history was disclosed and general epilepsy procedures were followed.

Verbatim wording from the response
“3. There was no seizure policy supplied upon admission. Southwinds general policy as to epilepsy was followed. Upon admission there was no indication that Mr Edwards had had seizures. If there is a history of seizures then it was usual for a specific policy for that resident to accompany upon admission, which would then be followed. Mr Edwards was not prescribed any epilepsy medication to the knowledge of Southwinds.”

Source location
2018-0015-Response-Southwinds-Limited
Page 2 · response
Published 7 March 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient training on atypical seizure and post-seizure behaviour

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure of care-home referral procedures for patients suffering seizures after recently sustained head trauma

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Failure to seek medical assistance following seizures

Use of a seizure policy not specific to the resident

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Respondent positions 3

Actions described in response 2

Respondent positions 1