The death of a patient with epilepsy

The Commission investigated a complaint about the care and treatment of a woman at a large
metropolitan hospital. The woman had a history of unusual epileptic seizures. She was admitted to the hospital to supervise her withdrawal from medication and to monitor her, to better understand and manage her seizures.

On the third night, the woman went to sleep at about 2.00am. Her sister was in the hospital room that night. When hospital staff went to wake the woman at 6.00am, they discovered that she had died.

The hospital reviewed the video used to monitor the woman. The video showed that the woman had rolled over in her sleep. At this time, the monitoring equipment had recorded a faster than normal heart rate. There were no obvious signs of a seizure that could be observed from the tape, nor had the woman’s sister noticed any seizure. The woman’s heart rate had then slowed and stopped.

The Coroner found that the woman had suffered a sudden unexplained death in epilepsy (‘SUDEP’).

The Commission investigated a complaint by the woman’s family about the hospital.

The Commission found that SUDEP may account for between 8% and 17% of deaths in  people with epilepsy. The risk factors include non-compliance with medication and poorly controlled seizures.

The hospital acknowledged that these risk factors for SUDEP had not been discussed with the woman before her admission.

The Commission made recommendations to the hospital, which were adopted as follows:

  • SUDEP as a risk factor is now discussed with all patients and their families prior to admissions for monitoring seizures.
  • The hospital gives a brochure on SUDEP written by the Epilepsy Foundation of Victoria to all patients admitted for monitoring.
  • Continuous pulse monitoring has been introduced, with alarms activated by reduced heart rate audible throughout the hospital unit.
  • Further training has been provided to the nursing staff.

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