LUCY PATRICIA COLGATE · Prevention of Future Deaths report

An inquest into the death of Lucy Patricia Colgate was opened on the 12th May 2020 and resumed on the 12th January 2021. The inquest concluded on 29th January 2021.

I found that the medical cause of her death was;

1a. Positional Asphyxia

1b. Uncontrolled Epilepsy

I concluded with a Narrative Conclusion:

Lucy Patricia Colgate suffered from generalised epilepsy which was poorly controlled on medication which had been appropriately prescribed. On the 28th March 2019 she had an epileptic fit at home and became wedged behind a door so that the door could not be opened. She was in a prone position. Paramedics attended promptly and managed to gain access to her within 20 minutes by which time she had suffered a hypoxic cardiac arrest through positional asphyxia and the effect of being in a post ictal state. She was taken by ambulance to Royal Surrey County Hospital but pronounced dead on arrival.

The circumstances of the death are detailed in the narrative conclusion.

The evidence showed that:
1. ████████ who was Lucy Colgate’s Consultant Neurologist gave evidence that the risks posed to epilepsy sufferers from locked doors is a recognised risk but that the risk posed by having inward opening doors to confined spaces is not widely appreciated. If the door had been outward opening Lucy Colgate is likely to have survived.