“Overall, after hearing evidence over two days regarding the administration of Mr Fisher's…”

The coroner’s concerns

Overall, after hearing evidence over two days regarding the administration of Mr Fisher's AED medication, I remain concerned that patients in the community are at risk of either being given medication that has been discontinued by a GP or not being given essential medication to control seizures. 1) I heard evidence from Mr Fisher's GP practice (Trinity Medical Centre) that they received a letter from Brighton Urgent Community Response (UCR) team indicating that they had, in turn, received a referral from the local Adult Social Care Team requesting a package of care assessment on 8 April. This assessment was carried out on 9 April and from handwritten medication administrative records (MAR) complied by the UCR Team from Brighton hospital, support was provided to Mr Fisher until 15 April. According to the UCR records this apparently included phenobarbital tablets twice a day even though Mr Fisher's GP had discontinued the phenobarbital on 8 April 2025. 3 liquid AEDs were also given including sodium valproate. 2) It is far from clear whether the UCR records are accurate regarding whether phenobarbital was given or not. The handwritten evidence says it was given but not whether this was from a blister pack or a separate box. Mr Fisher’s community pharmacist gave evidence that for some years he had dispensed phenobarbital in a separate box and not in a blister pack. 3) UCR then arranged for a care agency, Coastal Homecare, to take over supporting Mr Fisher. During the inquest I saw a referral form prepared by UCR confirming that Coastal Homecare were required to assist Mr Fisher three times a day to help with his personal care and medicine administration. However, the only medication information that was supplied by the UCR team to Coastal Homecare referred to blister packs and liquid medication including antibiotics for chest infection. No further details of current regular medication, dosage, timing or form of medication (eg blister pack, separate boxes or liquids) were provided at all. In addition, the antibiotics were only for a short number of days but no clear indication is given when they were to stop and may well have finished by the time Coastal took over care. 4) Coastal Homecare confirmed that an assessment of needs was carried out on 15 April 2025 by a supervisor attending Mr Fisher's home address. The UCR handwritten medication forms were used to digitally record the required medications into the Coastal Homecare electronic system. Initially I was told that photographs of the medication were taken as well but on checking no photographs could be recovered save one of skin creams. It is apparently not standard practice for photographs to be taken during this kind of assessment but during the inquest it was agreed this would be good practice in future to achieve greater clarity for daily carers who frequently change. 5) Coastal Healthcare indicated that a mistake was made when documenting the medications in that although the UCR handwritten forms included sodium valproate oral solution, this was not added at all into the Coastal Homecare electronic MAR chart. As a result, Coastal Homecare accepted that between 16 April to 21 April (6 days) Mr Fisher did not receive any sodium valproate oral solution. This was one of three liquid antiepileptic drugs Mr Fisher should have received to help control possible seizures. This mistake was Regulation 28 – After Inquest Template Updated 15/07/2025 TG 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 pharmcy who regularly dispensed Mr Fisher's medication. 6) Coastal Homecare management then self-reported the incident to the local Adult Safeguarding Team and also the Care Quality Commission but at the time of the inquest there has been no follow-up by either organisation to ascertain if there are any lessons to learn for the benefit of other vulnerable patients.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0166

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0