PFD report

LUCY PATRICIA COLGATE · Prevention of Future Deaths report

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Issued 12 Feb 2021•Surrey

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Inward-opening doors in confined spaces
  2. Lack of widespread appreciation of the risks of inward-opening doors in confined spaces
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Share learning about the death’s circumstances with paediatric specialty groups and OPEN UK to disseminate warnings about these risks.

    Stated by Royal College of Paediatrics and Child HealthStated plannedThe respondent said that this action was planned when they made their response on 16 February 2021.
  2. Action

    Monitor the number and type of enquiries on this topic and adapt responding materials accordingly.

    Stated by British Epilepsy Association (working name: Epilepsy ActionStated in progressThe respondent said that this action was in progress when they made their response on 16 February 2021.
  3. Action

    Update relevant printed information to extend advice from bathroom doors to doors securing any confined space.

    Stated by British Epilepsy Association (working name: Epilepsy ActionStated plannedThe respondent said that this action was planned when they made their response on 16 February 2021.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inward-opening doors in confined spaces

Wider context from the report

“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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of widespread appreciation of the risks of inward-opening doors in confined spaces

Wider context from the report

“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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Share learning about the death’s circumstances with paediatric specialty groups and OPEN UK to disseminate warnings about these risks.

Verbatim wording from the response

“We will share learning around the circumstances of this death with our paediatric specialty groups who lead care for children with epilepsy and with OPEN UK³ (Organisation of Paediatric Epilepsy Networks) to disseminate warnings of these types of risks. We hope”

Source location

2021-0042-Response-from-RCPCH-Redacted
Page 1 · response
Published 16 February 2021

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

Monitor the number and type of enquiries on this topic and adapt responding materials accordingly.

Verbatim wording from the response

“We will continue to monitor the number and type of enquiries we receive on this topic and adapt our responding materials accordingly.”

Source location

2021-0042-Response-from-Epilepsy-Action-Redacted
Page 1 · response
Published 16 February 2021

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

Update relevant printed information to extend advice from bathroom doors to doors securing any confined space.

Verbatim wording from the response

“• Have a bathroom door that opens outwards, or folds or slides open and closed. Then, if you fall against it during a seizure, you won’t block someone from getting in”

Source location

2021-0042-Response-from-Epilepsy-Action-Redacted
Page 1 · response
Published 16 February 2021

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

Amend online safety information to extend advice from bathroom doors to doors securing any confined space.

Verbatim wording from the response

“• Have a bathroom door that opens outwards, or folds or slides open and closed. Then, if you fall against it during a seizure, you won’t block someone from getting in”

Source location

2021-0042-Response-from-Epilepsy-Action-Redacted
Page 1 · response
Published 16 February 2021

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

Publish an Epilepsy Today article raising awareness of blocked-door risks and signposting available home-adaptation funding sources.

Verbatim wording from the response

“What else we will do During the course of 2021 we will publish an article in our magazine Epilepsy Today to raise awareness about this issue. This will include referencing and signposting people to sources of funding that might be available such as grants for home adaptations.”

Source location

2021-0042-Response-from-Epilepsy-Action-Redacted
Page 1 · response
Published 16 February 2021

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

Notify healthcare professional contacts about the issue and the organisation’s actions to guide appropriate patient advice.

Verbatim wording from the response

“During the course of 2021 we will notify our healthcare professional contacts about what we’re doing and why so as to increase their awareness about the issue and to guide them in providing appropriate advice to their patients.”

Source location

2021-0042-Response-from-Epilepsy-Action-Redacted
Page 1 · response
Published 16 February 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Monitor and share Epilepsy12 audit results with local and regional teams to encourage quality improvement.

    Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 16 February 2021.

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

Monitor and share Epilepsy12 audit results with local and regional teams to encourage quality improvement.

Verbatim wording from the response

“Children and young people with epilepsy need support to engage in an ongoing individualised assessment of risk and consideration of tailored accident prevention. The RCPCH Epilepsy12 audit supports trusts in England and Wales to measure on an ongoing basis how well they are evidencing risk assessment. The September 2020 report found that the majority (80%) of children and young people diagnosed with epilepsy had evidence of discussion regarding general participation and risk.¹ The RCPCH continue to monitor and share audit results with local and regional teams and further urge quality improvement in this area.”

Source location

2021-0042-Response-from-RCPCH-Redacted
Page 1 · response
Published 16 February 2021

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026