Coronial
WAhome

Inquest into the Death of Moss

Deceased

Sharon Beverley Moss

Demographics

40y, female

Date of death

2005-02-17

Finding date

2007-06-08

Cause of death

Sudden unexpected death in epilepsy (SUDEP); epileptic seizure

AI-generated summary

Sharon Beverley Moss, a 40-year-old woman with a long history of epilepsy, died on 17 February 2005 following a period of sleep deprivation ordered to facilitate a sleep-deprived EEG. She was found unresponsive in her home the morning after staying awake all night as instructed. The coroner found the death was due to sudden unexpected death in epilepsy (SUDEP). While sleep deprivation can lower the seizure threshold, the coroner found no definite causal link between the sleep deprivation and death. Key clinical concerns identified were: the consulting neurologist (a registrar) did not specifically explore whether the deceased had a known history of sleep deprivation triggering seizures, despite the deceased's mother later reporting this was a significant issue; and the deceased was not counselled about the risks or advised to have an adult present during the period of vulnerability. The coroner made recommendations that neurology departments implement checklists to systematically identify seizure triggers, and that practitioners ordering sleep-deprived EEGs should warn patients that tiredness may trigger seizures.

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

Specialties

neurologygeneral practice

Error types

communicationdiagnostic

Drugs involved

sodium valproate

Clinical conditions

epilepsygeneralised tonic-clonic seizuresudden unexpected death in epilepsy

Procedures

sleep-deprived electroencephalogram (eeg)

Contributing factors

  • Sleep deprivation ordered for sleep-deprived EEG
  • Inadequate exploration of personal seizure triggers during consultation
  • Possible unrecognised history of sleep deprivation as a seizure trigger
  • Living alone with only a 13-year-old child; no adult supervision during vulnerable period
  • No specific counselling about risks of tiredness during procedure preparation

Coroner's recommendations

  1. Heads of neurology at hospitals where EEGs are performed should draft a checklist designed to identify potential triggers for tonic-clonic seizures in patients to ensure that specific questions are asked about each likely trigger and none are inadvertently overlooked, particularly when inexperienced medical practitioners such as registrars see patients.
  2. The Australian and New Zealand Association of Neurologists should advise medical practitioners who order sleep deprived EEGs to warn patients that tiredness may be a trigger for seizures and that they may wish to take this into account in making arrangements for the period when they are likely to be unusually tired.
Full text
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Source and disclaimer

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