Finding into death of F M
Deceased
FM
Demographics
40y, female
Date of death
2019-03-02
Finding date
2026-01-16
Cause of death
Sudden unexpected death in epilepsy (SUDEP) in a woman with schizophrenia
AI-generated summary
FM, a 40-year-old woman with epilepsy and schizoaffective disorder, died from sudden unexpected death in epilepsy (SUDEP) at her disability group home. She had been prescribed periciazine (Neulactil) five days before death for anxiety management; no changes were made to her epilepsy regimen after a recent seizure. The Disability Services Commissioner identified suboptimal care practices: epilepsy monitoring equipment was not routinely checked or maintained per protocol, and overnight staff failed to conduct a mandatory visual check of FM at shift end. However, the coroner concluded these deficiencies did not cause or contribute to her death. The case highlights the importance of protocol adherence in disability care settings and the unpredictable nature of SUDEP, even with appropriate monitoring systems in place.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Epilepsy with known seizure triggers (excitement, temperature extremes, anxiety)
- Schizoaffective disorder (bipolar)
- Recent addition of periciazine to medication regimen
- Suboptimal care practices: failure to routinely check epilepsy monitoring equipment
- Failure to conduct mandatory visual checks of resident at shift end
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