Concerns raised 8 Insufficient medication verification during care-needs assessment View source Failure to prevent administration of GP-discontinued medication View source Failure to follow up medication incidents for learning affecting vulnerable patients View source Failure to provide complete current medication and stop-date information during care handover View source Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover View source Inaccurate or incomplete recording of medication administration View source Failure to liaise with the community pharmacy about regularly dispensed medication View source Risk of discontinued or essential seizure-control medication being incorrectly administered View source See 5 more concerns
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AI-generated summary
John Malcolm FISHER · 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
John Malcolm Fisher was admitted to hospital on 22 April 2025 with persistent focal seizures that developed into status epilepticus, and he died on 4 May 2025 after the seizures could not be controlled. The report raises concerns about inaccurate or incomplete medication information during transfers between community services and the omission of sodium valproate from the care agency’s medication record, resulting in six days without that medication.
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. The report was sent to Coastal Homecare – Hove Branch; that does not assign responsibility.
PFD Monitor interpretation Insufficient medication verification during care-needs assessment
Wider context from the report “4) Coastal Homecare confirmed that an assessment of needs was carried out on 15 April 2025 by a supervisor attending Mr Fisher's home address. The UCR handwritten medication forms were used to digitally record the required medications into the Coastal Homecare electronic system. Initially I was told that photographs of the medication were taken as well but on checking no photographs could be recovered save one of skin creams . It is apparently not standard practice for photographs to be taken during this kind of assessment but during the inquest it was agreed this would be good practice in future to achieve greater clarity for daily carers who frequently change.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coastal Homecare – Hove Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent administration of GP-discontinued medication
Wider context from the report “1) I heard evidence from Mr Fisher's GP practice (Trinity Medical Centre) that they received a letter from Brighton Urgent Community Response (UCR) team indicating that they had, in turn, received a referral from the local Adult Social Care Team requesting a package of care assessment on 8 April. This assessment was carried out on 9 April and from handwritten medication administrative records (MAR) complied by the UCR Team from Brighton hospital, support was provided to Mr Fisher until 15 April. According to the UCR records this apparently included phenobarbital tablets twice a day even though Mr Fisher's GP had discontinued the phenobarbital on 8 April 2025 . 3 liquid AEDs were also given including sodium valproate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coastal Homecare – Hove Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up medication incidents for learning affecting vulnerable patients
Wider context from the report “6) Coastal Homecare management then self-reported the incident to the local Adult Safeguarding Team and also the Care Quality Commission but at the time of the inquest there has been no follow-up by either organisation to ascertain if there are any lessons to learn for the benefit of other vulnerable patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coastal Homecare – Hove Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete current medication and stop-date information during care handover
Wider context from the report “3) UCR then arranged for a care agency, Coastal Homecare, to take over supporting Mr Fisher. During the inquest I saw a referral from prepared by UCR confirming that Coastal Homecare were required to assist Mr Fisher three times a day to help with his personal care and medicine administration. However, the only medication information that was supplied by the UCR team to Coastal Homecare referred to blister packs and liquid medication including antibiotics for chest infection. No further details of current regular medication, dosage, timing or form of medication (eg blister pack, separate boxes or liquids) were provided at all. In addition, the antibiotics were only for a short number of days but no clear indication is given when they were to stop and may well have finished by the time Coastal took over care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coastal Homecare – Hove Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover
Wider context from the report “5) Coastal Healthcare indicated that a mistake was made when documenting the medications in that although the UCR handwritten forms included sodium valproate oral solution, this was not added at all into the Coastal Homecare electronic MAR chart . As a result, Coastal Homecare accepted that between 16 April to 21 April (6 days) Mr Fisher did not receive any sodium valproate oral solution. This was one of three liquid antiepileptic drugs Mr Fisher should have received to help control possible seizures. This mistake was not spotted at all and there is no system in place to cross check what has previously been given when there is a handover between different care agencies nor was there any liaison with the community pharmacy who regularly dispensed Mr Fisher's medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coastal Homecare – Hove Branch; that does not assign responsibility.
PFD Monitor interpretation Inaccurate or incomplete recording of medication administration
Wider context from the report “2) It is far from clear whether the UCR records are accurate regarding whether phenobarbital was given or not. The handwritten evidence says it was given but not whether this was from a blister pack or a separate box. Mr Fisher’s community pharmacist gave evidence that for some years he had dispensed phenobarbital in a separate box and not in a blister pack.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coastal Homecare – Hove Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with the community pharmacy about regularly dispensed medication
Wider context from the report “5) Coastal Healthcare indicated that a mistake was made when documenting the medications in that although the UCR handwritten forms included sodium valproate oral solution, this was not added at all into the Coastal Homecare electronic MAR chart. As a result, Coastal Homecare accepted that between 16 April to 21 April (6 days) Mr Fisher did not receive any sodium valproate oral solution. This was one of three liquid antiepileptic drugs Mr Fisher should have received to help control possible seizures. This mistake was not spotted at all and there is no system in place to cross check what has previously been given when there is a handover between different care agencies nor was there any liaison with the community pharmacy who regularly dispensed Mr Fisher's medication .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Coastal Homecare – Hove Branch; that does not assign responsibility.
PFD Monitor interpretation Risk of discontinued or essential seizure-control medication being incorrectly administered
Wider context from the report “Overall, after hearing evidence over two days regarding the administration of Mr Fisher's AED medication, I remain concerned that patients in the community are at risk of either being given medication that has been discontinued by a GP or not being given essential medication to control seizures .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations