Louis Rogers
28 Mar 2023 · Coroner Karen Henderson · Surrey
The coroner's concerns
1. death from sudden unexpected death in childhood
“Management and investigation of Febrile Seizures”
2. insufficient information to identify early indicators of severe illness
“Information provided to parents/guardians after their child had a Febrile Seizure”
3. missed referral for complex febrile seizure management
“Improvement to and highlighting of the JRCALC guidelines for paramedic management of seizures in children”
4. lack of coordinated pathway causing diagnostic errors
“Febrile Seizure Pathway”
Responses
2023-0108-Response-from-Association-of-Ambulance-.pdf ↗· NHS England
Stated action
“We have taken an action to make all the medical directors and lead paramedics of UK ambulance services aware of the circumstances of [the deceased]' death and have asked them to review the JRCALC guidance and any local pathways or guidance in relation to decisions around conveying children after seizures.”
2023-0108-Response-from-Emergency-Care-Committee.pdf ↗· Royal College of Paediatricians
Stated action
“We are aware that increased body temperature can be a trigger for seizures in Dravet's syndrome and that these seizures may be of a complex nature (lasting longer than 15 minutes or occurring again within 24hr”
2023-0108-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“we will also be asking colleagues from each of the seven NHS regions to share the learnings from this matter and the guidance available with their Integrated Care Boards for cascading to relevant healthcare professionals.”
2023-0108-Response-from-NICE.pdf ↗· Royal College of General Practice
Stated action
“We believe that our guideline on epilepsies: diagnosis and management [CG137], which was in place at the time of [the deceased]' death, is directly relevant to this case. The guideline covered diagnosing, treating and managing epilepsy and seizures in children, young people and adults in primary and secondary care and made recommendations on what should happen following a first seizure (section 1.4), diagnosis (section 1.5) and investigations (sections 1.6). CG137 has since been replaced by our guideline”