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 draw physicians’ attention to the possibility of such an occurrence in drug literature or BNF entries
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 raised6
Failure to fully investigate prisoners’ reported episodes of loss of consciousness
Failure to conduct NICE-compliant investigations of loss of consciousness
Failure to make accurate and evidentially grounded entries in prisoners’ medical notes
Failure to conduct clinical investigations of prisoners experiencing loss of consciousness
Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol
Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness
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 raised4
Failure of emergency-response policy to require requesting duty doctor attendance
Failure of nursing staff to respond to collapses in a calm coordinated manner
Failure of nursing staff to apply basic life-support training
Lack of clear staff-response guidance for collapses
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
Review the Trust resuscitation policy to address emergency response guidance.
Stated by North London NHS Foundation Trust -
Action
Update the resuscitation policy with deteriorating-patient actions, an expanded NEWS Score, and a requirement to contact the duty doctor during medical emergencies.
Stated by North London NHS Foundation Trust -
Action
Revise and regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.
Stated by North London NHS Foundation Trust
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Action
Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.
Stated by North London NHS Foundation Trust -
Action
Introduce the step-by-step emergency-response guide in all other inpatient areas.
Stated by North London NHS Foundation Trust -
Action
Conduct unannounced resuscitation scenarios across Forensic wards to strengthen emergency response.
Stated by North London 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 resuscitation policy already listed actions for determining whether a collapsed patient was breathing and responding to such events.
Stated by North London NHS Foundation Trust
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Concerns raised9
Delays in medical treatment following pneumothorax
Failure to recognise pneumothorax on X-rays
Inadequate recording of nasogastric tube placement
Feeding via nasogastric tube before completion of full checks
Failure to record nasogastric tube feeding authorisation
Inappropriate use of nasogastric tubes for patients with advanced dementia and seizures
Unexplained gaps in clinical notes
Delays in forwarding and receiving X-ray reports from radiology
Breakdown in communication between junior doctors and consultants
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 access and read all relevant information across nursing and clinical records
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 raised5
Hand sanitiser gel stored within possible patient reach in A&E
Failure to keep A&E nursing notes complete and up to date
Failure to record nursing-observation frequency on the A&E whiteboard
Uncertainty over assessment on arrival at A&E
Failure to take hourly nursing observations in A&E
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
Check hand-gel dispensers regularly, keep them correctly located and maintained, and replenish them when required.
Stated by South Tees Hospitals NHS Foundation Trust -
Action
Make staff aware of the importance of keeping the area clean and tidy and reporting environmental problems immediately.
Stated by South Tees Hospitals NHS Foundation Trust -
Action
Return hand-gel dispensers to their correct locations throughout the department.
Stated by South Tees Hospitals NHS Foundation Trust
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Action
Remind nursing staff to complete and accurately record patient observations.
Stated by South Tees Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The department’s layout and distributed hand-gel dispensers meant staff did not have a significant distance to travel between cubicles.
Stated by South Tees Hospitals NHS Foundation Trust
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Position
The Trust found no evidence that Mr Collins could access hand gel at the nurses’ station or that this contributed to his death.
Stated by South Tees Hospitals NHS Foundation Trust -
Position
Trust policy considered the Early Warning Score insufficient to require medical review, so observation levels and frequency were managed under existing arrangements.
Stated by South Tees Hospitals NHS Foundation Trust
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Concerns raised3
Failure to correctly diagnose patients' conditions
Failure to provide truthful information about seeking clinical second opinions
Continued practice by a GP whose fitness to practice is in doubt
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The five-year statutory rule and unsuccessful exceptional-circumstances test prevented further investigation of the historical events and audit.
Stated by General Medical Council
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Position
Responsible Officer oversight, complaint reporting and periodic revalidation were considered sufficient to address concerns about current fitness to practise.
Stated by General Medical Council
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Concerns raised3
Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness
Failure to provide early medical attention for gradual onset stroke
Failure to seek medical opinion for prolonged unconsciousness
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
Provide all staff with first-aid and life-support training focused on the immediate care of unconscious residents.
Stated by Springbank Care Home Limited -
Action
Assess nurses’ competency in recognising consciousness levels, providing and documenting life support, conducting neurological observations, and following relevant guidance.
Stated by Springbank Care Home Limited -
Action
Instruct staff to summon emergency services promptly for unconscious residents, follow valid DNNAR instructions, and use a protocol available to all staff.
Stated by Springbank Care Home Limited
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Action
Inform nurse agencies and provide their head offices with the unconscious-person management protocol.
Stated by Springbank Care Home Limited -
Action
Provide the unconscious-person management protocol to occasional staff through agency induction materials.
Stated by Springbank Care Home Limited -
Action
Update residents’ risk assessments and care plans with specific information about causes of unconsciousness, including detailed epilepsy seizure types and recovery periods.
Stated by Springbank Care Home Limited
