Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate seizure recognition and post‑seizure behaviour training
The earlier warning
Duncan Tomlin · 12 Apr 2019 · Elisabeth Bussey-Jones, West Sussex
“Although epilepsy was not found to be causative in the death in this Inquest, in another situation with a similar set of circumstances,”
judiciary.uk/prevention-of-future-death-reports/duncan-tomlin
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 21 Jul 2022 · Gaia Pope-Sutherland · Rachael Griffin · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Duncan Tomlin · 12 Apr 2019
“Although epilepsy was not found to be causative in the death in this Inquest, in another situation with a similar set of circumstances,”
Later · Gaia Pope-Sutherland · 21 Jul 2022
“Police Officers provided evidence that they did not have training on epilepsy and mental health conditions such as post ictal psychosis, PTSD and those who have experienced sexual trauma”
What happened next
No web check of the stated actions has been published for this chain.