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Suspected epilepsy: when to warn

01 May 2013

A girl of eight, L, was brought by ambulance to the Emergency Department (ED) with a history of a fit during a lesson in school. There was no reliable history: according to friends who had been playing with L, she had touched an electrical socket, fallen, and then had a fit lasting about five minutes, from which she spontaneously recovered.

Shortly after L’s parents had arrived in the ED, she was seen by the on-call paediatric team. By this stage she had fully recovered. Her parents were keen to take her home. The on-call paediatrician noted that there were no signs of any acute infectious aetiology for the fit, and no evidence of any burn injury associated with an electrical discharge.

It was unclear whether a head injury had been sustained either before or during the incident. Because of uncertainty around the aetiology, a CT brain scan was performed. This was reported as normal. L’s parents were advised that further investigations would be organised as an outpatient, and to bring L back if any further episodes occurred. However: there was nothing in the notes to suggest the hospital intended to rule out anything serious, like epilepsy.

An electroencephalogram (EEG) was arranged for two weeks and a follow-up appointment was made for the paediatric outpatient clinic in six weeks in order to discuss the results of the EEG. Unfortunately, L did not attend for her EEG. The hospital did not have a ‘Did not attend’ policy in place, and no further action was taken by medical staff as a result of this.

Four weeks later, L was again brought into the ED by a teacher from her school. On this occasion the history was a little vague; it seemed that L had fallen to the ground, possibly as a result of a faint. It was unclear whether she had hit her head on a desk or on the floor. When on the floor, she had been noted to have some persistent blinking and unusual side-to-side movements of the head and one hand.

When examined in the ED about one hour after the episode, L was alert and co-operative. Neurological examination was unremarkable. A further CT brain scan was performed, and again reported as normal. On this occasion L’s parents were advised that further investigations including an echocardiogram and an EEG were necessary, that these would be arranged as an outpatient and that she would be seen in the paediatric department with the results of these.

She was discharged home with planned EEG and follow-up appointment booked for two weeks and four weeks respectively. Ten days later, L was found drowned in the bath at home. L’s parents made a claim against the hospital treating L.

Expert evidence on behalf of the parents advised that had the parents been made aware of the possibility of epilepsy as a diagnosis, and been given appropriate advice, that they would have prioritised the EEG appointment; and they would have followed standard advice given to parents of children with a diagnosis of epilepsy, ie, to ensure that she was supervised during baths, or to take only showers. The claim was settled for a moderate sum.

Learning points

  • Doctors may be faced with a dilemma when counselling parents about conditions in their child that are unconfirmed and still under investigation. There is a delicate balance to be found between causing undue anxiety if the condition is subsequently not diagnosed, and failing to provide parents with sufficient information for them to take appropriate precautions. In the case of a child who has had two episodes that are suggestive of a fit over a short period of time and in which investigations for epilepsy are underway, it would be prudent both to offer some precautionary advice to parents and to document the advice given.
  • In the UK, NICE’s clinical guideline 137 The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care, issued in January 2012, states that:
    1. All children, young people and adults with a recent onset suspected seizure should be seen urgently (ie, within two weeks) by a specialist (ie, a paediatrician with training and expertise in epilepsy). This is to ensure precise and early diagnosis and initiation of therapy as appropriate to their needs.
    2. Following a first seizure, essential information on how to recognise a seizure, first aid, and the importance of reporting further attacks should be provided to a child, young person or adult who has experienced a possible first seizure, and their family/carer/parent as appropriate. This information should be provided while the child, young person or adult is awaiting a diagnosis and should also be provided to their family and/or carers
    3. Children, young people and adults with epilepsy and their families and/or carers should be given information to include (where appropriate):
      • epilepsy in general
      • risk management
      • first aid, safety and injury prevention at home and at school or work.
    4. The time at which this information should be given will depend on the certainty of the diagnosis, and the need for confirmatory investigations.
  • In this instance, the parents’ failure to bring the child for the initial investigation may have been a contributory factor. Had a ‘Did not attend’ policy been in place, there would have been an opportunity to review the records and to establish whether further efforts should have been made to ensure that the child was brought for medical assessment or treatment.