Aaron Forte, a 24-year-old man with epilepsy, Jacob's XXY Syndrome, intellectual disability, and schizophrenia, died of sudden unexpected death in epilepsy (SUDEP) while in specialist disability accommodation. He was found unresponsive on his bedroom floor at 8:00 AM on 31 August 2023 after being observed breathing normally at 7:00 AM. His epilepsy was managed with lamotrigine, zonisamide, and clobazam; medications were at therapeutic levels post-mortem. The coroner found Aaron received appropriate care including 24-hour supervision, hourly overnight checks, seizure monitoring, and staff-administered medications ensuring good adherence. Although Aaron was not seen in the neurology clinic after his June 2023 ED presentation (discharged with medication adjustments pending clinic follow-up), the coroner concluded the care was appropriate and his death was not preventable, as SUDEP prevention relies primarily on seizure control, which had improved with recent medication changes.
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