Select SUDEP or Non-SUDEP to filter concerns and reports. Counts are PFD reports, not deaths.
About this dataset
We searched all 6,433 reports in the published corpus using a fixed text-search method, then assessed 317 candidates against source-based inclusion criteria. Ninety reports were included. Epilepsy had to be materially relevant to the death or a substantive coroner’s concern; incidental mentions were excluded.
Eligibility and SUDEP assignment were assessed with GPT-5.6 Sol and checked for valid source quotations. Assignment uses a balance-of-probabilities threshold: SUDEP or non-SUDEP must be more likely than not on the report’s evidence. The exact term SUDEP need not appear. Genuinely unclear eligible reports remain in All only. These are model-assisted documentary assessments, not independently validated clinical diagnoses.
The search can miss reports with sparse terminology or incomplete source text. This dataset does not represent all epilepsy deaths. Recurring concerns and responses are taken from the existing published evidence. Published corpus snapshot: 7 September 2026. Cohort selection updated 5 November 2026. The title shows the first and last included reports’ publication dates.
Reports over time
Matching reports published each year within the selected date range.
* 2026 is projected from reports observed to 7 Sep 2026.
Only concerns related to the selected recurring concern and their linked actions and positions are shown. Other concerns are counted within each report.
Actions and positions describe what recipients stated in published responses. Select a statement to read its source wording.
West Sussex, Brighton and Hove
Concerns raised4
Failure to prevent administration of GP-discontinued medication
Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover
Inaccurate or incomplete recording of medication administration
Risk of discontinued or essential seizure-control medication being incorrectly administered
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.
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.15
Action
Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Provide staff with Plexus shared-care-record access for real-time GP medication summaries.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Update the MAR chart SOP with guidance on discontinued medicines remaining in patients’ homes and mandatory GP second checks for discrepancies.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Complete a formal review of the MAR chart SOP for UCR and Home First services.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Deliver staff briefings and training aligned with the revised MAR chart SOP after approval.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Embed pharmacy support within the UCR and General Virtual Ward model for complex or unclear medication regimes.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Conduct a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Photograph all medicines present at assessment and onboarding for every new care package.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require all staff to complete additional Epilepsy Awareness training.
Stated by Coastal Homecare (Hove) Ltd.Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Attend Local Authority training on epilepsy awareness, seizure management, and buccal midazolam.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Record each person’s dispensing pharmacy and require escalation to relevant healthcare professionals when medication discrepancies or uncertainties arise.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Stated by Sussex Community NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Staffordshire and Stoke-on-Trent
Concerns raised1
Failure to maintain a reliable written basis for Brivaracetam dosage administration
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.
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.4
Action
Update weekly and monthly managers’ medication audits to verify written authorisation, dosage changes and timely receipt of replacement prescriptions.
Stated by Godfrey CareStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Update staff medication competency assessments to test clarification of unclear directions, MAR-label discrepancies and verbal medication changes.
Stated by Godfrey CareStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The delay in administering medication did not contribute to the death.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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