A 74-year-old man with epilepsy passed away in hospital after a home care provider failed to administer one of his prescriptions because of an error, according to an official report.

John Fisher was taken to the Royal Sussex County Hospital in Brighton on April 22, 2025, following seizure episodes.

In a prevention of future deaths document, assistant coroner Karen Taylor noted that the pensioner’s convulsions could not be managed despite medical intervention and he succumbed on May 4.

Taylor expressed worry in her report about how Mr Fisher’s medication was handled. She explained that six days before his hospital stay, he missed a dose of one of his epilepsy medications while receiving support from Coastal Homecare.

An inquest determined that an error occurred when Mr Fisher’s prescriptions were being recorded during the process of setting up home-based care.

Taylor noted her continued concern that individuals living independently may either receive medications their doctor has stopped or miss crucial drugs needed to manage their condition.

Mr Fisher began experiencing seizures in November 2019 and received an epilepsy diagnosis in December 2020. He commenced treatment with antiepileptic medications, including sodium valproate.

He required two hospital admissions during 2021 and was released with four separate prescriptions.

Mr Fisher remained free of seizures for four years until his admission in April 2025.

Mr Fisher accessed assistance from Brighton Urgent Community Response, operated by Sussex Community NHS Foundation Trust, between April 9 and April 15. During this period, records show he was administered phenobarbital tablets twice daily.

Taylor noted that this drug had actually been cancelled by Mr Fisher’s GP on April 8.

The assistant coroner remarked that it was unclear whether the UCR documentation correctly reflects whether phenobarbital was actually administered.

Support for Mr Fisher was subsequently arranged through the agency Coastal Homecare.

The organisation conducted a needs evaluation on April 15 and transcribed required medications from NHS digital records.

Coastal Homecare acknowledged that an error occurred during the medication recording process, which meant that from April 16 to April 21, Mr Fisher received no sodium valproate oral solution.

Taylor commented that this error went entirely unnoticed and no procedure existed to verify what had previously been supplied when care responsibilities transferred between organisations, nor was there any contact with the local pharmacy that consistently provided Mr Fisher’s prescriptions.

The provider voluntarily reported the matter to the adult safeguarding team and the Care Quality Commission.

Taylor directed the prevention of future deaths report to Sussex Community NHS Foundation Trust and Coastal Homecare’s Hove Branch.

A spokesperson for Sussex Community NHS Foundation Trust said their thoughts go out to Mr Fisher’s family during this difficult time. They added that they are carefully examining the findings and will respond thoroughly to the coroner in due course.

Coastal Homecare was also invited to provide a response.