Inquest into the Death of TS (Subject to a Suppression Order)

10y · Male·Unascertained but consistent with epileptic seizure (SUDEP)

A 10-year-old boy in state care died from Sudden Unexpected Death in Epilepsy (SUDEP). With seizures since 2007, he presented to Princess Margaret Hospital in 2009 with an abnormal EEG; however, recommended follow-up investigation was not performed due to family loss to follow-up. Taken into state care in 2010 for inappropriate clonidine use by parents, he was managed by a general paediatrician who concluded no further seizure investigation was needed after six months without reported seizures. A paediatric neurologist later opined that further EEG testing and anticonvulsant treatment would have been optimal medical management. The child died at home four days after discharge from routine follow-up. While improved seizure investigation and treatment might have reduced risk, the coroner found such intervention would not have guaranteed prevention of the fatal seizure.