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A 74-year-old epilepsy patient died in hospital after a change of care provider led to him not receiving his prescribed sodium valproate oral solution for six days, a coroner has reported. 

John Malcolm Fisher died in Royal Sussex County Hospital in Brighton on May 4, 2025 after being admitted with regular focal seizures on April 22, writes Karen Taylor, assistant coroner for West Sussex, Brighton and Hove in a report to prevent future deaths published earlier this week. 

His condition had developed into status epilepticus, meaning the seizures “were continuing without a break so there was no recovery period in between,” wrote Ms Taylor. 

Mr Fisher first experienced seizures in November 2019 after surgery and was started on anti-epileptic drugs (AEDs) including sodium valproate. 

Following two successive hospital admissions in 2021, he was put on four AEDs, including valproate and phenobarbital, and remained free of seizures for nearly four years.

The inquest into Mr Fisher’s death heard that care agency Coastal Homecare took over his care in April 2025 after this was arranged by the Brighton Urgent Community Response (UCR) team.

The UCR team documented Mr Fisher’s medicines regimen on April 9, 2025. This included three liquid AEDs as well as phenobarbital tablets, despite his GP having discontinued the latter medication the previous day. 

“It is far from clear whether the UCR records are accurate regarding whether phenobarbital was given or not,” wrote Ms Taylor, noting that while his community pharmacy dispensed the drug in a separate box there is no record of any boxed medicines in the handover the UCR team supplied to Coastal Homecare.

Coastal Homecare visited his home address on April 15 to carry out a needs assessment and make a note of the required medications using handwritten forms, but a “mistake was made” that meant Mr Fisher’s sodium valproate oral solution was not added to his electronic chart. 

Ms Taylor wrote: “This mistake was not spotted at all and there is no system in place to cross-check what has previously been given when there is a handover between different care agencies.  

“Nor was there any liaison with the community pharmacy who regularly dispensed Mr Fisher’s medication.” 

Coastal Homecare, whose management self-reported the incident to the local safeguarding team and to the Care Quality Commission, accepted that for six days (April 16-21, 2025) Mr Fisher did not receive any sodium valproate oral solution.

The assistant coroner’s report was issued to the Hove branch of Coastal Homecare and to Sussex Community NHS Foundation Trust, who are obliged to respond by May 13 outlining any actions they have taken or proposals for changes to their care pathways.