Man died after epilepsy medication error, coroner warns
A 74-year-old man died after not receiving essential epilepsy medication in the days before he was admitted to hospital, a coroner has found.
John Malcolm Fisher died on 4 May 2025 at Royal Sussex County Hospital after suffering uncontrollable seizures.
Assistant coroner Karen Taylor concluded that Mr Fisher’s death followed a series of failures in how his anti-epileptic medication was recorded and administered in the community.
Mr Fisher, who had been diagnosed with epilepsy in 2020, had remained seizure-free for almost four years before being admitted to hospital on 22 April 2025 with persistent seizures.
His condition deteriorated rapidly, developing into status epilepticus – a life-threatening condition where seizures continue without recovery between them.
An inquest heard that, in the days leading up to his admission, there were concerns about missed doses of key medication, including sodium valproate, which is used to control seizures.
Mr Fisher had been receiving care from Sussex Community NHS Foundation Trust and Coastal Homecare. The coroner found that during a handover between services, critical information about his medication was not properly shared.
A handwritten medication record compiled by NHS teams was later transferred into a digital system by the care agency. However, a key drug – sodium valproate oral solution – was not included, meaning Mr Fisher did not receive it for six days.
The coroner said the error went unnoticed and highlighted the absence of a system to cross-check medications during transitions between care providers. There was also no liaison with Mr Fisher’s community pharmacy, which regularly dispensed his prescriptions.
“It was far from clear” from the records whether some medications had been administered at all, the report noted, raising wider concerns about the accuracy of documentation.
Despite treatment in hospital, including additional medication and specialist care, Mr Fisher’s seizures could not be controlled. A decision was made with his family to move to end-of-life care, and he died days later.
In a Prevention of Future Deaths report, Ms Taylor warned that similar failures could happen again without changes to how medication is recorded, communicated and verified between services.
She has called for action to reduce the risk to other vulnerable patients, particularly those receiving care from multiple providers in the community.
Both the NHS trust and Coastal Homecare have expressed condolences to Mr Fisher’s family and said they will respond to the coroner’s findings.
They have until 13 May 2026 to outline what action will be taken.