SUDEP Action

Making every epilepsy death count
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Inquiries into individual deaths

Coroners’ rulings on avoidable epilepsy-related deaths

England and Wales

In England and Wales, all sudden deaths should be investigated by the Coroner.  Recent reforms in the coronial system have meant Coroners have the power to make a special ruling under regulation 28 (formally known as rule 43).  This is where the coroner considers a death may be avoidable and where future deaths could be prevented if specific actions are put in place.  The aim of a regulation 28 is to draw the attention of local health bodies or other agencies to an area of concern and to seek their response by completing a report to prevent future deaths (also known as PFD reports). 


PDF icon Coronial rulings on avoidable epilepsy deaths

Coroner ruling pre-2013

2011 Inquest into death of 
James Stephens


In Scotland sudden deaths are investigated by a Procurator Fiscal.  Occasionally the Procurator Fiscal will highlight an issue of public interest to the Crown Office and recommend a public inquiry.  The aim of a public inquiry is to make recommendations to protect the public interest. 

2011 Inquiry into the deaths of Erin Casey and Christina ilia  
2002 Inquiry into the death of Colette Findlay