Finding into death of F M

40y · Female·Sudden unexpected death in epilepsy (SUDEP) in a woman with schizophrenia

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.