Epilepsy, 19 Sep 2013 – 19 Jun 2026
Epilepsy-related Prevention of Future Deaths reports
All dates19 Sep 2013 – 7 Sep 2026
Select SUDEP or Non-SUDEP to filter concerns and reports. 3 reports could not be assigned and remain in All only. 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.
Most frequent recipients
Matching reports sent to each recipient.
Most commonly raised concerns
Non-SUDEP 68 reports 19 Sep 2013 – 7 Sep 2026
Reset- Incomplete, inaccurate or unavailable clinical and care recordsClinical and care records are incomplete, inaccurate, inconsistent, unavailable or otherwise unreliable for safe care.5 reportsSelected
- Unsafe medication administrationA recurring failure of the medication-administration system to ensure that medicines are administered safely, accurately, promptly and as prescribed.5 reportsSelected
- Inadequate driver licensing controls for road safetyDriver licensing systems do not reliably identify, record, review or restrict drivers whose inexperience, health or vehicle-related risk requires additional safeguards.4 reportsSelected
- Unreliable seizure care and managementControls dedicated to recognising, assessing, monitoring, responding to and managing seizures are not reliably provided.4 reportsSelected
- Failure to communicate clinically important information reliably between care servicesRecurring concern that clinically important guidance, decisions and patient information are not kept accurate, current and available to the clinicians and emergency services who need them.3 reportsSelected
- Failure to ensure clinical investigation results are reliably available, interpreted and acted uponRecurring deficiency in the end-to-end management of clinical investigation results, including their availability, transmission, checking, review, interpretation, follow-up and escalation when needed.3 reportsSelected
- Failure to provide required medication promptly when clinically neededThe anchor identifies delayed prescribing of a patient's usual medication after an unexpected admission, while another report identifies delayed prescribing and non-provision of urgent therapeutic medication. These support a recurring concern about timely provision of clinically required medication rather than only the anchor's admission or prescribing-step failure.3 reportsSelected
- Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crisesReports identify insufficient police training to recognise and respond safely to mental-health crises and behaviour-related medical emergencies.3 reportsSelected
- Insufficient qualified healthcare staffing capacityHealthcare services lack enough appropriately qualified staff to provide the required clinical coverage and patient care safely for the workload, acuity and specialist needs.3 reportsSelected
- Unreliable DVLA medical fitness notification arrangementsThe anchor identifies limited professional awareness and uncertain effectiveness of guidance for notifying the DVLA about medically relevant driving risks. A different report identifies clinicians failing to advise patients with cough syncope to stop driving and notify the DVLA, while another identifies failure to notify the DVLA of relevant medical conditions. These support the named DVLA medical-fitness notification process rather than guidance awareness alone.3 reportsSelected
- Electronic patient records failing to make relevant clinical information available and actionableRecurring concern that electronic patient-record systems do not reliably present, preserve, share or prompt action on clinically relevant information across the patient’s care.2 reportsSelected
- Failure to conduct required welfare checks on people in distressThe anchor identifies a risk that care home staff will not check a resident in distress, while a different canonical report identifies failure to conduct a later welfare check on a person left in potential medical distress. Together these support a recurring concern about welfare checks not being completed when a person may require assistance.2 reportsSelected
- Failure to identify and address recurring safety issues through organisational learningDifferent reports identify failures of reporting, review and learning arrangements to retain, recognise and address substantive or recurring patient-safety issues, rather than merely failures to complete one specific corrective action.2 reportsSelected
- Failure to reliably learn from medication incidents and implement safeguardsThe medication incident learning process is unreliable: incidents are not consistently followed up or reviewed to identify, communicate and implement safeguards that protect patients from recurrence.2 reportsSelected
- Failure to reliably recognise and respond to acute clinical deteriorationClinical deterioration is not reliably recognised, monitored, escalated and acted upon with the urgency it requires.2 reportsSelected
- Failure to seek medical attention when a person's condition warrants itReports identify an unreliable escalation control in which care staff or other responders do not promptly seek medical or paramedic assistance when a person's injury, pain, fall or deterioration warrants clinical attention.2 reportsSelected
- Inadequate control of illicit substance use and supply in secure institutionsThe anchor identifies an ongoing failure to mitigate illicit substance entry, distribution and use in a secure hospital, while assertions from different reports identify continuing illicit-drug influx, widespread access and weak supply-reduction controls in prisons. These distinct manifestations support a bounded concern about controlling illicit substances in secure institutional settings, rather than only room searches, drug testing or a prison-specific strategy.2 reportsSelected
- Inadequate controls on contraband mobile phones in prisonsDifferent reports identify failures in the prison control system for preventing and mitigating access to contraband mobile phones, including their easy availability to prisoners and their use to facilitate drug dealing and other prison-security risks.2 reportsSelected
- Inadequate recording of medication prescribing decisionsReports identify unreliable medication prescribing records that can obscure prescribing status, rationale, changes or safety-critical decisions and thereby allow unsafe medication to be prescribed or administered.2 reportsSelected
- Inadequate staff competence to provide first aidReports identify an unsafe first-aid capability condition across healthcare, care, custody and other staff. The recurring concern is the unreliability of staff competence to recognise emergencies and provide appropriate first aid, rather than any single training, refresher, assessment or practical-performance failure.2 reportsSelected
- Unreliable Care Programme Approach care coordinationReports identify different failures within the named Care Programme Approach, including the absence of a structured medication review and failures to allocate coordinators, complete required reviews, maintain care plans and follow up patients. Together these support a recurring concern with the reliable operation of CPA care coordination rather than medication review alone.2 reportsSelected
- Unreliable RIO clinical-record functionsThe anchor identifies an unclear timeliness standard for RIO entries, while different reports identify failures of RIO to support complete information capture, cross-team access and usable observation records. Together these support a recurring concern with the reliability of the named RIO clinical-record system rather than only one entry-timing or documentation manifestation.2 reportsSelected
- Unreliable communication of patient-care information between clinical staffClinical staff responsible for the same patient's care do not reliably exchange relevant information about care, treatment and risk.2 reportsSelected
- Unreliable escalation by care staff for required medical attentionCare staff do not reliably recognise and escalate deterioration, pain or other safety concerns to obtain timely medical assessment or advice.2 reportsSelected
- Unreliable healthcare patient transfer processesHealthcare transfers do not reliably provide the procedures, responsibility, documentation and clinical information needed for safe movement and continuity of care.2 reportsSelected
- Unreliable hospital discharge processesHospital discharge does not reliably bring together planning, clinical readiness, relevant organisations, safe execution and required follow-up.2 reportsSelected
- Unreliable implementation of medication changesReports identify different failures in the medication-change process, including failure to act on a prescribed reduction, failure to ensure carers acknowledge changes, and difficulty implementing specialist-directed changes accurately. Together these support the wider unsafe condition that medication changes are not reliably implemented across prescribing, communication and follow-up controls.2 reportsSelected
- Unreliable medication dosage verification and communicationReports identify unsafe failures to ensure that medication dosages are accurately verified, clarified and communicated across prescribing, dispensing and administration activities.2 reportsSelected
- Unreliable mental health referral pathwaysReports identify different failures within the mental health referral process, including referrals not being made when indicated, received referrals not being actioned, and frontline practitioners lacking clarity about when and where to refer. These support a recurring concern with the reliability of mental health referral pathways rather than any single referral or awareness failure.2 reportsSelected
- Unreliable patient observation arrangementsPatient observation systems do not reliably set, support and deliver the observation level required by assessed safety risk.2 reportsSelected
- Unreliable review and action on clinically significant incoming correspondenceReports identify failures across the incoming clinical-correspondence process, including failure to identify GP medication-review requests, failure to bring action-requiring correspondence to medical staff, and correspondence being filed without GP review or action. The shared unsafe condition is that clinically significant correspondence may not reliably reach the responsible clinician or trigger the required clinical response.2 reportsSelected
- Unreliable safety CCTV monitoring systemsDifferent reports identify failures in the operation of CCTV used as a safety control, including absent staff access arrangements, inadequate coverage, non-working cameras, insufficient monitoring and unclear staff instructions. Together these support the reliability of safety CCTV monitoring as the parent concern rather than any single access, coverage, equipment or training failure.2 reportsSelected
- Unsafe medication prescribingReports identify unsafe prescribing decisions in which the medication, indication, dose or relevant clinical circumstances are not adequately evaluated before prescribing.2 reportsSelected
Reports matching this classification
19 Sep 2013 – 7 Sep 2026 · 68 reports
ResetShowing all concerns and their linked actions and positions from reports in this date range for non-sudep. Select a recurring concern above to narrow the evidence.
Actions and positions describe what recipients stated in published responses. Select a statement to read its source wording.
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Concerns raised1
Failure to record observed or reported epileptic events occurring to employees at work
Responses linked to these concernsEach 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.2
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Action
Amend return-to-work procedures to record reported epileptic events and remind staff to review individual risk assessments and refer employees for occupational-health assessment when necessary.
Stated by Wm Morrison Supermarkets plc -
Action
Update first-aid training and policy to require slips for every attendance, including cases without treatment or an available first aider, and train People Managers to review and file slips.
Stated by Wm Morrison Supermarkets plc
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Morrisons can only record events disclosed to it because equality legislation prohibits requiring employees to disclose epilepsy information.
Stated by Wm Morrison Supermarkets plc
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Concerns raised1
Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers
Responses linked to these concernsEach 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.3
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Action
Implement a jointly authored procedure defining custodial and healthcare responsibilities for conveying summary medical information to receiving A&E departments.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Share the information-transfer procedure at the Offender Health Learning the Lessons Forum to support adoption by other establishments.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Undertake a compliance review of the information-transfer procedure to confirm full implementation of the system.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Lack of a mechanism ensuring essential medications are prescribed, dispensed and administered
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to proactively ask and record the type of fit during triage calls
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised8
Failure to maintain an up-to-date Status Epilepticus protocol
Failure to promulgate the Status Epilepticus protocol to all relevant medical staff
Failure to establish lawful authority for detaining an agitated patient
Failure by ITU doctors to prioritise brain protection
Failure to understand the need for and method of escalating care to HDU or ITU
Failure of ITU registrar attendance at the ward when required
Inadequate clarity, accuracy and completeness of medical and nursing notes
Insufficient junior medical staffing capacity
Responses linked to these concernsEach 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.14
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Action
Revise the Trust’s Status Epilepticus Policy using current clinical guidance.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Include the Status Epilepticus Policy in the mandatory Junior Doctor Grand Round.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Disseminate the Status Epilepticus Policy through junior doctor training, medical team discussions and the Trust intranet.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Action
Promote Deprivation of Liberty Safeguards principles through executive bulletins and Trust-wide posters.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Monitor Deprivation of Liberty Safeguards compliance and timescales through weekly reports to the Director of Quality and Governance.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Employ a Lead Nurse to advise staff and monitor compliance with Deprivation of Liberty Safeguards processes.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Work with local-authority Deprivation of Liberty Safeguards leads and Mental Capacity Advocates on safeguarding processes.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Deliver continuing Mental Capacity and Deprivation of Liberty Safeguards training for Trust staff, including the scheduled May 2016 session.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Change and review the Critical Care Unit processes and care pathway.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Revise and publish Critical Care admission, discharge and escalation standards, including National Early Warning Score guidance.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Revise nursing documentation and reinforce Ward Manager and Matron monitoring of documentation quality.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Audit key aspects of medical clinical documentation through the Trust’s Clinical Audit programme.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Review medical staffing rotas to maximise senior cover and monitor staffing levels.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Continue recruiting medical staff and collaborate with Health Education North West and junior doctors to improve training experience and long-term attraction.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical condition.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised2
Failure to follow up a GP’s identification of a relevant consultant
Limited investigation into health conditions declared on form POLN3
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure of RIO to support complete recording and accessibility of patients' epilepsy information
Failure to maintain effective bathing observations for patients with epilepsy
Responses linked to these concernsEach 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.6
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Action
Add a specific physical-health-risk prompt to the overarching RiO risk assessment form.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Build and release electronic epilepsy assessment forms in OpenRiO for Learning Disability and other relevant Trust services.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Promote Learning Disability Service Specific Guidance for recording physical-health risks, including epilepsy, in RiO.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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Action
Collate results from epilepsy, bathing-risk and physical-health audits to inform further improvements.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Communicate the OpenRiO release and explain use of the electronic epilepsy forms through Trust-wide, divisional and governance channels.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Finalise and ratify the Trust-wide protocol for safe bathing and showering of people with epilepsy.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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Concerns raised2
Insufficient overnight ward staffing capacity for patient workloads
Unavailability of overnight additional staffing resources
Responses linked to these concernsEach 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
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Action
Drive a nurse recruitment strategy to recruit the registered nurses required for medical wards to adopt the new staffing model.
Stated by Sherwood Forest Hospitals NHS Foundation Trust -
Action
Monitor staffing levels and their impact on quality and safety through the Trust Board and Quality Committee.
Stated by Sherwood Forest Hospitals NHS Foundation Trust -
Action
Provide assessed enhanced one-to-one care day and night using ward, bank or agency staffing when additional resources are required.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
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Action
Implement the approved nursing staffing model of five registered and two unregistered staff by day and three registered and one unregistered staff by night.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Medical wards cannot adopt proposed staffing levels until approximately 100 additional registered nurses are recruited, anticipated to take a further 12 months.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
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Concerns raised4
Failure to complete movement logs accurately and with sufficient detail
Lack of a written handover between evening and night supervisors
Daily logs failing to provide accessible and reliable information
Lack of a clear central method for accurately recording significant medical events
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure of sodium valproate blood test reference ranges to clearly indicate the therapeutic range
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
