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
All classifications 90 reports 19 Sep 2013 – 7 Sep 2026
- Unreliable seizure care and managementControls dedicated to recognising, assessing, monitoring, responding to and managing seizures are not reliably provided.9 reportsSelected
- Incomplete, inaccurate or unavailable clinical and care recordsClinical and care records are incomplete, inaccurate, inconsistent, unavailable or otherwise unreliable for safe care.7 reportsSelected
- Unsafe medication administrationA recurring failure of the medication-administration system to ensure that medicines are administered safely, accurately, promptly and as prescribed.6 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.4 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
- 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.4 reportsSelected
- Unreliable hospital discharge processesHospital discharge does not reliably bring together planning, clinical readiness, relevant organisations, safe execution and required follow-up.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 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
- Failure to provide timely clinical follow-up after medication prescribingPrescribed medication is not reliably followed up for effectiveness, safety, collection, adherence and patient response.3 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.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
- 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.3 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.3 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.3 reportsSelected
- Unreliable patient observation arrangementsPatient observation systems do not reliably set, support and deliver the observation level required by assessed safety risk.3 reportsSelected
- 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.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 communicate safety-critical care information effectively between care providers and familiesReports identify unsafe communication between care providers and families, including failures to convey risks, care instructions, concerns or other information needed to support safe care and decision-making.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 ensure safe prisoner transfersRecurring concern that the end-to-end prisoner transfer process is unreliable, leaving transferred prisoners exposed to unmanaged risks or interruptions in essential support.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 document the rationale for consequential decisionsDifferent reports identify missing or inadequate records explaining the rationale and evidential basis for consequential decisions, including the anchor’s crucial decisions and comparable mental-capacity, NRPF and transfer decisions. The shared concern is unreliable rationale documentation for decisions that affect safety, accountability and continuity of care, rather than any one decision type or record system.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 reliably refer patients to required specialist servicesThe anchor identifies a required physiotherapy referral that was not completed. A different report identifies delayed referrals to physiotherapy, occupational therapy, dietetics and Parkinson’s specialist services. Together these support an end-to-end concern with required specialist referrals not being made promptly and reliably, rather than a concern limited to one physiotherapy referral.2 reportsSelected
- Failure to secure and control medicationReports 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
- 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
- Incomplete clinical history-takingReports identify an unsafe clinical assessment condition in which relevant patient history is not obtained sufficiently to support recognition of symptoms, risks and appropriate care.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 access to emergency communicationReports identify failures in dedicated emergency communication arrangements that can delay summoning or contacting emergency help.2 reportsSelected
- Unreliable communication of critical medication information to GPsRecurring 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
- 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 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 inter-agency information sharing for coordinated careThe 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
- 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
- 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 observation of people in custodyThe anchor report identifies failure to transfer and replicate medically required observation levels when a detained person moves into GEO AMEY custody, while a different report identifies uncertainty about whether the correct observation level, including constant watch, was provided to a person in prison custody. Together these support a recurring concern about the reliability of the custody observation process rather than only one handover or level-setting failure.2 reportsSelected
- Unreliable recording of required observations in care and custodyDifferent reports identify inaccurate, delayed, anticipatory or falsified records of required observations, including 15-minute observations in prison custody and patient-care settings. The shared unsafe condition is that observation records do not reliably reflect when and how observations were actually conducted, rather than any one observation frequency, recording location or electronic system.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
- Unreliable urgent mental health referral and assessment pathwaysUrgent mental-health referral pathways do not reliably secure timely access, coordination and specialist assessment.2 reportsSelected
- Unreliable welfare-check processes for people whose health is of concernThe anchor identifies unclear purpose and use of the welfare sheet for monitoring prisoners whose health is of concern. A separate report identifies inconsistent criteria for what constitutes a welfare check and when it is recorded. Together these support a recurring concern with the reliability of the bounded welfare-check process, rather than only the sheet or recording component.2 reportsSelected
- 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
- 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
All reports in this date range
19 Sep 2013 – 7 Sep 2026 · 90 reports
Showing all concerns and their linked actions and positions from reports in this date range. 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 raised3
Failure to provide closer monitoring for prisoners with seizure activity
Failure to conduct start-of-day prisoner welfare checks
Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers
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.1
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Action
Implement Personal Management Plans to obtain consent, share relevant medical alerts and guidance, record required observations, and review at multidisciplinary prison meetings.
Stated by Oxleas NHS Foundation Trust
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Concerns raised1
Failure of the vehicle ownership system to prevent purchase and retention of cars by unlicensed drivers
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.1
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Position
The law does not require a driving licence to register or keep a vehicle, including where the keeper will not drive it.
Stated by Department for Transport
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Concerns raised12
Failure of Mental Health teams to provide assessment information directly to GPs
Lack of policy for handling sexual harassment or assault in DHUFT inpatient units
Lack of police officer knowledge of life-threatening illnesses and their behavioural impact
Failure to flag key information on DHUFT RiO records
Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Lack of DHUFT policy for contact with patients’ families
Failure to create, complete and store Dorset Police records appropriately
Delay in AMHP feedback of Mental Health Act assessment information to GPs
Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies
Lack of resourcing of epilepsy services
Ambiguity and inconsistency in access to Community Mental Health care processes
Lack of communication between neurology and psychiatric teams
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.34
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Action
Develop and implement a RiO template for Section 12 doctors to send key Mental Health Act assessment information directly to GPs, with corresponding guidance and SOP amendments.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Implement an updated standard operating procedure governing information flow after Mental Health Act assessments.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Continue applying the 72-hour requirement for distributing completed Mental Health Act assessment reports.
Stated by Bournemouth, Christchurch and Poole Council
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Action
Discuss with Approved Mental Health Professionals how to succinctly share information with GPs, highlighting information of immediate relevance.
Stated by Bournemouth, Christchurch and Poole Council -
Action
Engage with Dorset Healthcare Trust to agree amendments to the Pan-Dorset Standard Operating Procedure for information distribution.
Stated by Bournemouth, Christchurch and Poole Council -
Action
Implement internal reporting to monitor 72-hour initial reports, track full reports, and share monthly performance information with senior managers.
Stated by Dorset Council -
Action
Require AMHPs to complete mandatory internal training on confidential information sharing following Mental Health Act assessments.
Stated by Dorset Council -
Action
Reduce the timeframe for forwarding the initial completed AMHP report to the assessed person’s GP from seven days to 72 hours.
Stated by Dorset Council -
Action
Develop, approve and disseminate a procedure for supporting patients affected by sexual violence and responding to reported sexual incidents.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Update the Safeguarding policy and add appendices covering responses to sexual abuse disclosures in hospital and community settings.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Complete consideration of higher-level medical-condition training and conclude that the current policing approach remains appropriate.
Stated by College of Policing -
Action
Include epilepsy, psychosis, medical conditions, medication and associated risks in operational first-aid training.
Stated by Dorset Police -
Action
Update RiO training and provide a standalone e-learning module on using the alerts system, promoting it to existing users and staff.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Develop and publish RiO guidance explaining how to view, add and remove alerts.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Embed the adopted missing-person policy changes into working practice.
Stated by Dorset Police -
Action
Review the concern-for-welfare policy to incorporate current physical and mental ill-health trends and professional guidance.
Stated by Dorset Police -
Action
Implement revised call-handling, deployment and grading policies with risk assessment and performance monitoring.
Stated by Dorset Police -
Action
Evaluate how revised policies affect deployment decisions and complete the commissioned external audit.
Stated by Dorset Police -
Action
Establish a working group to co-produce, ratify and circulate a Working with Families and Carers policy covering communication, engagement and the Think Family approach.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Include log-keeping and recording in Vulnerability 4 training.
Stated by Dorset Police -
Action
Send organisation-wide guidance reminding staff and officers about accurate and transparent record keeping.
Stated by Dorset Police -
Action
Upgrade Niche and require relevant staff to record decisions and key information in locked, chronological logs.
Stated by Dorset Police -
Action
Deliver Vulnerability 4 training on welfare, missing-person and deployment policies to relevant staff and officers.
Stated by Dorset Police -
Action
Disseminate the updated missing-person policy and provide recurring contact-centre refresher training.
Stated by Dorset Police -
Action
Recruit a temporary part-time Band 7 specialist epilepsy nurse for one day per week, supporting transition to adult epilepsy care.
Stated by University Hospitals Dorset NHS Foundation Trust -
Action
Appoint and establish a full-time Band 4 epilepsy coordinator role supporting the specialist epilepsy nurses and patient care.
Stated by University Hospitals Dorset NHS Foundation Trust -
Action
Work collaboratively with the Integrated Care Board to assist its review of the epilepsy and neurology service.
Stated by University Hospitals Dorset NHS Foundation Trust -
Action
Review the impact of the temporary Band 7 specialist nurse post to inform development of a substantive staffing model and funding.
Stated by University Hospitals Dorset NHS Foundation Trust -
Action
Undertake an eight-week review of Dorset epilepsy nursing resources, provision across care settings, relevant specialty interactions, and neurology–psychiatry communication processes.
Stated by NHS Dorset Integrated Care Board -
Action
Request the Epilepsy Advisory Group’s views on epilepsy nursing numbers, resourcing, and how additional resources could work.
Stated by Association Of British Neurologists -
Action
Continue implementing the CMHT/STWB interface and screening meetings through an updated standard operating procedure.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Participate in co-designing a new integrated community mental health operational model through the MHICC transformation programme.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Support solutions to poor integration and communication between neurological and mental health services.
Stated by Royal College of Psychiatrists -
Action
Discuss with the Royal College of Psychiatrists’ President how to improve communication between psychiatric and neurology teams.
Stated by Association Of British Neurologists
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.16
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Position
Existing AMHP requirements and quality assurance arrangements already require recording and sharing assessment outcomes within specified timescales.
Stated by Bournemouth, Christchurch and Poole Council
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Position
The Trust’s discharge-information procedure and statutory Mental Health Act guidance are relied upon to address communication after mental health assessments.
Stated by Department of Health and Social Care -
Position
Full AMHP reports cannot be completed within 72 hours because shift patterns and rota arrangements prevent timely completion.
Stated by Dorset Council -
Position
Comprehensive training on epilepsy and mental health conditions is considered impractical because medical conditions and missing-person circumstances are too complex and variable.
Stated by College of Policing -
Position
Existing first aid, vulnerability training and authorised professional practice are considered proportionate and appropriate for responding to medical risks.
Stated by College of Policing -
Position
Responsibility for national training updates on life-threatening illnesses rests with the College of Policing through its clinical governance process.
Stated by Dorset Police -
Position
No further action is identified for RiO significant-event flags because their use already forms part of the Trust’s training programme.
Stated by Dorset Healthcare University NHS Foundation Trust -
Position
A wholesale review of record keeping across all systems has not been undertaken because targeted improvements are considered a necessary and proportionate response.
Stated by Dorset Police -
Position
Reducing the information-feedback timeframe is a decision for Dorset Council and BCP Council, with the Trust able to update its SOP only after agreement.
Stated by Dorset Healthcare University NHS Foundation Trust -
Position
Cannot assess epilepsy nursing numbers because the organisation lacks access to the relevant workforce data.
Stated by Association Of British Neurologists -
Position
The Trust maintains that the patient did not meet CMHT eligibility criteria at the identified discharge and assessment points.
Stated by Dorset Healthcare University NHS Foundation Trust -
Position
The Trust considers transformation work a more effective response than training staff on the existing CMHT access model.
Stated by Dorset Healthcare University NHS Foundation Trust -
Position
The Trust disputes that staff misunderstand or face ambiguity about accessing community mental health services or discharging patients.
Stated by Dorset Healthcare University NHS Foundation Trust -
Position
Existing national training, professional development and clinical guidance arrangements are relied upon to support community mental health practice and discharge planning.
Stated by Department of Health and Social Care -
Position
Communication between neurology and psychiatric teams concerns national bodies rather than the Trust, so the Trust will not comment further.
Stated by Dorset Healthcare University NHS Foundation Trust -
Position
Responsibility for improving communication between neurology and psychiatric teams lies nationally, not with the local Trust.
Stated by University Hospitals Dorset NHS Foundation Trust
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Concerns raised4
Failure to use emergency transport for a medical emergency
Failure to prevent arrest-related bias from influencing assessment of urgency
Failure to ensure a suitably qualified clinician is available to provide emergency treatment during transport
Failure to recognise the combination of seizures and cocaine as a medical emergency
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
Review existing primacy-of-care guidance and improve its accessibility with examples of when paramedics should attend patients directly.
Stated by London Ambulance Service NHS Trust -
Action
Share the PFD report with the JRCALC Chair for consideration of further review of guidance on cocaine use and seizure activity.
Stated by London Ambulance Service NHS Trust -
Action
Produce and publish an internal clinical refresher for frontline clinicians on cocaine-related risks and red-flag presentations.
Stated by London Ambulance Service NHS Trust
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 care did not reflect a lack of urgency, and arrest did not influence the timeliness or appropriateness of assessment, management or care.
Stated by London Ambulance Service NHS Trust
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Position
Existing JRCALC clinical guidelines already provide detailed guidance on cocaine use, including specifically addressing seizure activity.
Stated by London Ambulance Service NHS Trust
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Concerns raised1
Failure to use clear and non-confusable communication and expression of numbers for medication dosages
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 accept recommendations to carry and administer buccal midazolam when necessary
Failure to ask parents whether the child had vomited
Lack of paramedic training in the use of buccal midazolam
Lack of evidence of paramedic training following an independent Serious Incident Report and agreed recommendations
Failure to attempt alternative oxygenation
Failure to attempt suction
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
Develop and present a business case for moving to buccal midazolam, using gathered data and liaison with other ambulance trusts.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Begin the governance and legal process for transitioning from the current anticonvulsant medication to buccal midazolam.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Add permission to administer buccal midazolam to the Scope of Practice Policy for paramedic staff.
Stated by East Midlands Ambulance Service NHS Trust
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Action
Develop an action plan covering training for staff who access or administer buccal midazolam, including patient-held medication.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Assess the impact of adding buccal midazolam to the medicines formulary, including effectiveness, access, storage and alternative treatments.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Develop a clinical bulletin reinforcing systematic seizure management, aspiration assessment and maintenance of oxygenation during patient transfer.
Stated by East Midlands Ambulance Service NHS 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
No audit of buccal midazolam training was required because it was not in the medicines formulary at the time.
Stated by East Midlands Ambulance Service NHS Trust
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Position
Suction was not required because the child did not vomit while the crew was present.
Stated by East Midlands Ambulance Service NHS Trust -
Position
Continual bagging during transfer was technically challenging because safe movement down the stairs could not be ensured.
Stated by East Midlands Ambulance Service NHS Trust
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Concerns raised1
Lack of training on temporal lobe epilepsy-related ictal automatism during restraint
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.5
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Action
Update and circulate the ABD Training Package for UK police forces, directing immediate delivery of the revised package.
Stated by National Police Chiefs’ Council -
Action
Circulate emergency medicine best-practice guidelines on excited delirium and acute behavioural disturbance to police forces.
Stated by National Police Chiefs’ Council -
Action
Obtain specialist emergency and forensic medicine advice on ABD training materials and trainer guidance.
Stated by National Police Chiefs’ Council
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Action
Continue reviewing learning from coroners, oversight bodies, stakeholders and police forces to inform restraint and self-defence training.
Stated by National Police Chiefs’ Council -
Action
Review and update the ABD PowerPoint and Personal Safety Training Manual with additional restraint training.
Stated by National Police Chiefs’ Council
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
Existing ABD training materials and package updates address the concern, with the arrangements remaining subject to continual review.
Stated by National Police Chiefs’ Council
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Concerns raised2
Shortage of qualified radiology staff
Insufficient MRI scanner capacity and availability
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.10
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Action
Develop an expanded imaging workforce, including increased radiographer and radiologist training, new Imaging Training Academies and innovative imaging technologies.
Stated by NHS England -
Action
Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.
Stated by NHS England -
Action
Operate the Greater Manchester Imaging Network to coordinate regional imaging workforce and infrastructure development.
Stated by NHS Greater Manchester Integrated Care Board
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Action
Increase the substantive radiologist workforce and establish additional advanced reporting and sonographer capacity.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Develop a five-year North West imaging workforce implementation plan to guide local implementation plans for the three integrated care systems.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Develop the North West Imaging Workforce Strategy through collaboration among the three regional imaging networks.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Prioritise Diagnostic Radiography in Greater Manchester Allied Health Professions career events during 2021–22.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Increase imaging equipment capacity in England to address diagnostic service demand.
Stated by NHS England -
Action
Develop community diagnostic hubs to expand access to MRI, CT, ultrasound and X-ray services, including for inpatient activity.
Stated by NHS England -
Action
Maintain additional outpatient MRI capacity through the mobile scanner, operating 12 hours daily, seven days a week.
Stated by NHS Greater Manchester Integrated Care Board
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
Each integrated care system’s workforce team is responsible for delivering local imaging workforce priorities.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised2
Failure of GP registration processes to enable registration without relevant documentary proof
Failure to resolve the interagency Care Programme Approach process
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 raised3
Failure to inform the DVLA of medical conditions relevant to safe driving
Failure to advise drivers of the legal requirement to notify the DVLA of medical conditions
Failure to advise drivers of the impact of their medical conditions on safe driving
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.1
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Action
Write to patients with epilepsy or Parkinson’s disease to remind them of DVLA notification responsibilities and identify current drivers for record updates.
Stated by Emsworth Surgery
