Overview
- In April 2026, a coroner delivered a narrative conclusion that Kiara Ainsworth, 13, died after an epileptic seizure in the bath while unsupervised and after missing three doses of her medication.
- Her family had asked the GP practice for a repeat prescription in the days before her death, the request was handled as routine, and she took her last known dose the day before she died.
- A hospital consultant’s November 27 instruction to raise her levetiracetam dose was not carried out by the GP due to an administrative error, leaving her on a lower dose for months.
- The GP practice says it has overhauled how it handles consultant letters, added a pharmacist to ease workload, and completed two audits that found all medication letters now reach pharmacists.
- Epilepsy nurses had advised showers or supervised shallow baths to cut drowning risk, yet the mother said the shower was broken, while social services records did not note a faulty shower and a final visit days earlier reported mother and daughter were doing well.