Inquest into death of Sebastian Nicholas Pelle

20y · Male·sudden unexplained death in epilepsy (SUDEP); right frontal lobe epidermal cyst a significant contributing condition

A 20-year-old man with a history of seizures and a previously resected frontal lobe cyst presented to hospital with severe headaches. Despite his significant medical history of epilepsy and prior neurosurgery, he was discharged the same day without neuroimaging (CT/MRI scan), given only analgesia and paracetamol-codeine. He died of sudden unexplained death in epilepsy (SUDEP) the following morning. Expert review by a neurologist concluded that a non-contrast CT scan should have been performed, hospital admission was warranted based on his clinical features and history, and the failure to scan was outside accepted medical practice. While death could not have been predicted, hospitalization might have enabled prompt seizure management and resuscitation, potentially preventing a fatal outcome.