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Finding into death of Kieran Joseph McGuinness

Deceased

Kieran Joseph McGuinness

Demographics

37y, male

Coroner

Coroner David Ryan

Date of death

2022-09-11

Finding date

2024-01-16

Cause of death

Sudden unexpected death in epilepsy (SUDEP) in the setting of acquired brain injury with post traumatic epilepsy

AI-generated summary

Kieran McGuinness, 37, died of sudden unexpected death in epilepsy (SUDEP) following acquired brain injury with post-traumatic epilepsy. He was found unresponsive on his apartment floor on 11 September 2022, having been found in the hallway the previous day by a disability support worker. The worker believed Kieran was intoxicated and left him on the floor to 'sober up' without considering seizure as a differential diagnosis, despite Kieran's known seizure risk and recent hospitalisation for seizures. His seizure management plan required calling an ambulance for unresponsiveness or prolonged seizures. The coroner found an opportunity for escalation of care was missed. Key lessons: disability support workers require training to recognise seizures versus intoxication, understand when to escalate care, and follow seizure management protocols even when alternative explanations seem plausible.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

neurosurgeryneurologypsychiatryemergency medicine

Error types

diagnosticcommunicationdelay

Drugs involved

levetiracetamtopiramateolanzapinelacosamide

Clinical conditions

sudden unexpected death in epilepsypost-traumatic epilepsyacquired brain injuryliver cirrhosisalcohol use disorder

Procedures

craniectomysubdural haematoma evacuationsubgaleal haematoma evacuation

Contributing factors

  • Failure to recognise potential seizure activity
  • Misattribution of presentation to acute alcohol intoxication
  • Non-escalation of care despite known seizure risk
  • Inconsistent application of seizure management plan
  • Alcohol use disorder
  • Non-compliance with medications
  • Acquired brain injury with post-traumatic epilepsy

Coroner's recommendations

  1. Dynamic Care Services provide training to staff on epilepsy and seizure management, with particular emphasis on circumstances requiring ambulance call
Full text

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