Daniel Stickland · Prevention of Future Deaths report

On 28th May 2014 I commenced an investigation into the death of Daniel Stickland aged 17. The investigation concluded at the end of the inquest on 13th February 2015. The conclusion of the inquest was death from natural causes;
Medical cause of death:
1.a Sudden Cardiac Death with Morphologically Normal Heart
2.Epilepsy

On the 14th May 2014 the deceased was found collapsed having fallen from bed at his residential school St Edwards. He had been under investigation for seizures but no diagnosis had been made. Earlier that day he had had two seizures now recognised as indicating a form of epilepsy and after the second emergency services were called but did not take him to hospital. On the information presented and in the way presented from non -medically trained school staff and from their own observations of Daniel the emergency personnel felt there was no need to do so. Daniel was taken to Southampton General Hospital where he was pronounced dead the following day.

(1)Lack of a written handover between evening and night supervisors at St Edwards School
(2)Movement log that was not completed accurately or with enough detail
(3)Daily log that was not easily accessible and was misleading
(4)No clear method of centrally and accurately recording significant medical events to facilitate passage of information to non -school persons.