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.
Most frequent recipients Respondents Types
Matching reports sent to each recipient.
HM Prison and Probation Service 1
Practice Plus Group 1
Sheffield Health Partnership University NHS Foundation Trust 1
Executive agency 1
Independent healthcare provider 1
NHS trust 1
01 Unreliable seizure care and management Controls dedicated to recognising, assessing, monitoring, responding to and managing seizures are not reliably provided. 3 reportsSelected 02 Failure to provide required medication promptly when clinically needed The 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. 2 reportsSelected 03 Failure to reliably learn from medication incidents and implement safeguards The 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 04 Failure to secure and control medication Reports identify medication as remaining accessible, unsecured or inadequately controlled, creating risks of misuse, overdose, theft or access by people other than the intended patient. 2 reportsSelected 05 Inadequate control of illicit substance use and supply in secure institutions The 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 06 Inadequate controls on contraband mobile phones in prisons Different 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 07 Inadequate driver licensing controls for road safety Driver licensing systems do not reliably identify, record, review or restrict drivers whose inexperience, health or vehicle-related risk requires additional safeguards. 2 reportsSelected 08 Incomplete, inaccurate or unavailable clinical and care records Clinical and care records are incomplete, inaccurate, inconsistent, unavailable or otherwise unreliable for safe care. 2 reportsSelected 09 Unreliable DVLA medical fitness notification arrangements The 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. 2 reportsSelected 10 Unreliable communication of critical medication information to GPs Recurring deficiency in the medication-information exchange process between services and GPs, including information needed to maintain supplies, assess prescribing safety and support continuity of treatment. 2 reportsSelected 11 Unreliable hospital discharge processes Hospital discharge does not reliably bring together planning, clinical readiness, relevant organisations, safe execution and required follow-up. 2 reportsSelected 12 Unreliable implementation of medication changes Reports 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 13 Unreliable inter-agency information sharing for coordinated care The anchor identifies absent agreed communication means and inaccessible shared patient information between mental health agencies. Other canonical reports identify relevant risk information not being shared between agencies and poor inter-agency information sharing preventing coordinated care, supporting a recurring concern with the reliability of inter-agency care information sharing rather than only the anchor's repository or communication-channel failure. 2 reportsSelected 14 Unreliable patient observation arrangements Patient observation systems do not reliably set, support and deliver the observation level required by assessed safety risk. 2 reportsSelected 15 Unreliable review and action on clinically significant incoming correspondence Reports 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 16 Unsafe interoperability between prison custody and healthcare procedures Reports 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 17 Unsafe medication administration A recurring failure of the medication-administration system to ensure that medicines are administered safely, accurately, promptly and as prescribed. 2 reportsSelected
Classification: all classifications Recurring concern: Unreliable inter-agency information sharing for coordinated care
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.
Concerns raised 1
Failure to communicate clinically relevant information between services about epilepsy and psychosis View source
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.
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AI-generated summary
Bryan Andrews and Mary Andrews · 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
Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.
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 communicate clinically relevant information between services about epilepsy and psychosis
Wider context from the report “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths.
This led to significant time lapses in treatment and rejection of referrals, most notably:
i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation.
He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service.
ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines.
iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this.
iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist.
v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed.
vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out.
vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team.
viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened.
ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner.
x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral.
The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion.
” Source location Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
Open source report
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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 Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.
Verbatim wording from the response “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:” Source location Response from Sheffield Health and Social Care
Open published response
16 Jan 2024 Trevor Alan MONERVILLE · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1
Inadequate communication about prisoners’ health conditions View source
This report raised 5 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.
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AI-generated summary
Trevor Alan MONERVILLE · 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
Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.
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 Inadequate communication about prisoners’ health conditions
Wider context from the report “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing , between the prison staff and family , briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate.
Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security, thus preventing the cell from being searched for retained medication.
” Source location Trevor Alan MONERVILLE · Prevention of Future Deaths report
Open source report
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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 Work with NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.
Verbatim wording from the response “HMPPS recognises that, information sharing is vital to effective health management of people in prison and is working closely with NHSE to increase staff confidence and support effective information sharing by offering clarity about the general and routine sharing of health information and where risk/safeguarding concerns have been raised.” Source location Response from HM Prison and Probation Service
Open published response
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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 Implement Regional Multi Professional Complex Case Clinic escalation for the most complex patients.
Verbatim wording from the response “Practice Plus Group operates an integrated healthcare model. Any patients pending transfer back to the main wing with ongoing needs are to be discussed at the Multi Professional Complex Case Clinic (MPCCC) prior to transfer. This allows oversight of all departments within the integrated team and a holistic complex care plan to be created. The MPCCC is led by the GP, attended by all clinical leads, and any relevant staff involved in patient care. For individual cases prison partners may be invited to attend and a care plan created with a named coordinator allocated. Practice Plus Group has now implemented a further point of escalation to Regional MPCCC. For the most complex of patients, attendees will include healthcare, prison staff and, on occasion, representatives from NHS England.” Source location Response from Practice Plus Group
Open published response
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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 Practice Plus Group cannot resolve integration of healthcare and prison IT systems because SystmOne is commissioned by NHS England and medical records are confidential.
Verbatim wording from the response “As to lack of integration of various systems, this is not an issue that Practice Plus Group can resolve. SystmOne is commissioned by NHS England and Practice Plus Group is commissioned to use SystmOne. As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.” Source location Response from Practice Plus Group
Open published response
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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 Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
Verbatim wording from the response “There are Information Sharing protocols in place, as directed by national policy, which underpin the exchange of information between healthcare and prison staff. There are several regular meetings involving healthcare and prison staff where individual issues are raised and addressed, including the Safety Intervention Meeting and Multi-Disciplinary Complex Case Clinic, both of which are held weekly.” Source location Response from HM Prison and Probation Service
Open published response
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Classification: all classifications 7 Sep 2023 – 7 Sep 2026 (Publication date) Recurring concern: Unreliable inter-agency information sharing for coordinated care
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