Finding into death of Simon Mark Everill
Deceased
Simon Mark Everill
Demographics
55y, male
Date of death
2014-09-14
Finding date
2016-06-07
Cause of death
Complications of right middle cerebral artery infarction
AI-generated summary
Simon Mark Everill, a 55-year-old man with intellectual disability and epilepsy, suffered a right middle cerebral artery infarction on 3 September 2014 after experiencing two falls during a day service activity. His symptoms—including altered consciousness, weakness, and facial drooping—were initially attributed to an epileptic seizure by carers and the locum general practitioner. There were delays in calling the ambulance and potential miscommunication regarding urgency between the locum doctor and disability support workers. However, the coroner found these delays unlikely to have altered the outcome given the patient's history of seizures with similar presentations. Staff caring for Mr Everill were found to have acted diligently and professionally. The clinical lesson is that acute stroke symptoms can be difficult to distinguish from seizure activity in patients with epilepsy, particularly when falls are common.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- falls on 3 September 2014 (two incidents)
- low blood glucose levels (around 5 mmol/L and later 2.7 mmol/L)
- delayed recognition of stroke symptoms by carers
- misinterpretation of symptoms as seizure activity
- delay in contacting ambulance
- possible miscommunication regarding urgency between locum GP and support workers
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