Epilepsy, 19 Sep 2013 – 19 Jun 2026

Epilepsy-related Prevention of Future Deaths reports

All dates19 Sep 2013 – 7 Sep 2026

Custom range

Based on PFD publication date. Dates are available up to the published snapshot: 7 Sep 2026. Preset periods end on this date.

90All reports 19SUDEP 68Non-SUDEP

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.

Department for Education1
Department for Transport1
George Abbot School1
Greenshades Coach Travel Limited1
Pentonville Prison1
Practice Plus Group1
Surrey County Council1

Most commonly raised concerns

SUDEP 19 reports 19 Sep 2013 – 7 Sep 2026

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  1. Unreliable seizure care and managementControls dedicated to recognising, assessing, monitoring, responding to and managing seizures are not reliably provided.5 reportsSelected
  2. Failure to provide timely clinical follow-up after medication prescribingPrescribed medication is not reliably followed up for effectiveness, safety, collection, adherence and patient response.2 reportsSelected
  3. 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
  4. Incomplete, inaccurate or unavailable clinical and care recordsClinical and care records are incomplete, inaccurate, inconsistent, unavailable or otherwise unreliable for safe care.2 reportsSelected
  5. Unreliable hospital discharge processesHospital discharge does not reliably bring together planning, clinical readiness, relevant organisations, safe execution and required follow-up.2 reportsSelected
  6. Unreliable management of medication doses not takenThe anchor identifies missing guidance for monitoring prescribed medication that self-administering patients do not take when dispensed. A different report identifies inconsistent procedures for responding when service users refuse or do not take medication. Together these support a recurring concern with the reliability of detecting, monitoring and escalating omitted or refused medication doses, rather than a concern limited to one guidance document or one home's procedure.2 reportsSelected
  7. Unsafe cell-sharing decisions for prisonersRecurring deficiencies in the prison cell-sharing risk system can leave prisoners exposed to unsafe pairings or prevent them from understanding changes affecting their cell-sharing status.2 reportsSelected
  8. Unsafe interoperability between prison custody and healthcare proceduresReports identify failures in the bounded interface between prison custody, contracted custody providers and healthcare services, where procedures, responsibilities and safety-relevant information do not operate together reliably.2 reportsSelected

Reports matching this classification and recurring concern

19 Sep 2013 – 7 Sep 2026 · 2 reports

Classification: sudepRecurring concern: Inadequate staff competence to provide first aid
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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.

  1. Inner North London

    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.

    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

    Lack of ongoing first aid training for prison officers

    Wider context from the report

    “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low. One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.) A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead. ”

    Source location

    Amarjit SINGH · 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

    Low first aid understanding among prison officers

    Wider context from the report

    “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low. One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.) A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead. ”

    Source location

    Amarjit SINGH · 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

    Publish, introduce and circulate the national First Aid and Emergency Aid Manual to prison staff at HMP Pentonville.

    Verbatim wording from the response

    “The HMPPS National Health and Safety Arrangements for First Aid and Emergency Aid Manual was published and introduced in August 2023 and this was circulated to all prison staff at HMP Pentonville.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 22 September 2023

    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

    Distribute emergency response pocket cards to prisons and staff as reminders of how to respond to medical emergencies.

    Verbatim wording from the response

    “should be called. In 2021, all Prisons were also issued with a supply of emergency response pocket cards which were shared with staff. The cards provided an instant reminder of how to respond to a medical emergency. In March 2022, a further supply of the emergency response pocket cards were issued to Regional Group Safety Leads for them to share with their prisons.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 22 September 2023

    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

    Issue emergency response guides to all prisons, covering required actions and circumstances for calling a medical emergency response code.

    Verbatim wording from the response

    “At a national level, new emergency response guides were issued to all prisons which set out the actions required of staff in a medical emergency, including all the circumstances listed in the PSI 03/2013 Medical Emergency Response Codes under which a medical emergency response code”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

    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

    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
    Page 2 · response
    Published 22 September 2023

    Open published response
  2. Surrey

    AI-generated summary

    Christopher James B Sears · 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

    Christopher James B Sears, a 13-year-old boy, died on 13 November 2014 after a seizure-like episode on a school bus; resuscitation attempts were unsuccessful. The report raised concerns about the absence of Basic Life Support training and emergency protocols for school-bus drivers, delays in calling emergency services, and difficulties alerting the bus company where there was no formal diagnosis.

    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

    Lack of requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training

    Wider context from the report

    “1. There is no requirement for bus companies tendering for contracts from Local Authorities to transport pupils/students to ensure all their drivers have undergone training in Basic Life Support. ”

    Source location

    Christopher James B Sears · 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

    Lack of a Basic Life Support qualification requirement for pupil-transport drivers

    Wider context from the report

    “2. There is no requirement for drivers transporting pupils/students to hold a Basic Life Support qualification. ”

    Source location

    Christopher James B Sears · 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

    Consult on a revised version of the guidance on school transport.

    Verbatim wording from the response

    “It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third ‘Matter of Concern’). We intend to consult on a revised version of the guidance on school transport in the autumn. Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols.”

    Source location

    2016-0212-Response-by-Department-for-Education
    Page 1 · response
    Published 25 May 2016

    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

    Consider clarifying training expectations for school bus drivers and escorts, including basic life support and emergency healthcare protocols.

    Verbatim wording from the response

    “It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third ‘Matter of Concern’). We intend to consult on a revised version of the guidance on school transport in the autumn. Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols.”

    Source location

    2016-0212-Response-by-Department-for-Education
    Page 1 · response
    Published 25 May 2016

    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

    Responsibility for requiring bus companies to provide drivers with basic life support training rests with the Department for Transport.

    Verbatim wording from the response

    “Your concern that LA contractual arrangements do not require tendering bus companies to ensure that their drivers are qualified in basic life support skills is a matter for the Department for Transport (DfT), and we understand that Andrew Jones is replying separately to you on this issue.”

    Source location

    2016-0212-Response-by-Department-for-Education
    Page 1 · response
    Published 25 May 2016

    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

    Mandatory basic life-support training for bus drivers is not proposed because existing guidance and flexible Driver CPC arrangements are considered sufficient.

    Verbatim wording from the response

    “The Driver CPC is purposely designed to be flexible in its application – no specific part of the periodic training syllabus is mandatory, and the Department believes that this is important to ensure that training can be focussed on every individual’s specific training needs. In 2014/15 275,900 drivers chose to undertake training courses that taught them either basic or more advanced first aid techniques; while that total includes both bus and HGV drivers, it nevertheless suggests strong take-up.”

    Source location

    2016-0212-Response-by-Department-for-Transport
    Page 2 · response
    Published 25 May 2016

    Open published response

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Classification: sudep19 Sep 2013 – 7 Sep 2026 (Publication date)Recurring concern: Inadequate staff competence to provide first aid
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