Sebastian Nicholas Pelle died on 26 July 2016 at the aged of 20 years in Campbell in the Australian Capital Territory. Mr Pelle's death was reported to the ACT Coroner because no doctor had provided a certificate as to the cause of Mr Pelle's death.

Mr Pelle had previously complained of headaches and suffered from seizures and attended the Canberra Hospital (TCH) on the morning before his death complaining of unbearable pain in his head. The Coroner found that the manner and cause of Mr Pelle's death was sudden unexplained death in epilepsy (SUDEP). The Coroner concluded that Mr Pelle did not receive appropriate care and treatment by TCH on the day prior to his death and that a referral of Mr Pelle's treating doctors to the Medical Board was appropriate.

Background Facts

On a number of occasions since August 2015, Mr Pelle had complained of severe headaches and suffered from seizures. On one particular occasion on 8 November 2015, Mr Pelle had a seizure and was transported to the Canberra Hospital (TCH) by ambulance, where he underwent emergency surgery to remove a lesion on his frontal lobe. After the surgery, it was recommended that Mr Pelle take a short course of anticonvulsant medication and undergo regular screening tests to check on possible regrowth of the cyst removed from his frontal lobe.

Mr Pelle suffered another seizure on 1 January 2016 and was admitted to St Vincent's Hospital in Sydney, where he was released and instructed to continuing taking his anticonvulsant medication. An MRI was conducted on Mr Pelle on 7 April 2016 and no further growth of the lesion in his frontal lobe was visible. On 24 July Mr Pelle began to complain of a 'bad headache' however, he did not wish to attend hospital. On the following day, 25 July 2016, Mr Pelle attended his workplace for an hour until he complained of unbearable pain in his head and called his mother to have her take him to TCH. While at TCH, Mr Pelle had some blood tests conducted and an intravenous analgesia given to him but the hospital did not perform any scans of his head and discharged him the same day. Upon discharge Mr Pelle was given a prescription for Panadeine Forte and told to return to hospital if the headaches persisted.

Later on the evening of 25 July, around 10pm, Mr Pelle complained to his father of a headache. On the morning of 26 July 2016, around 7am, Mr Pelle's mother discovered him deceased in his bed. The death was then reported to the ACT Coroner in accordance with s 13(1)(3) of the Coroners Act 1997 (ACT), as no doctor had provided a death certificate as to the cause of Mr Pelle's death

Associate Professor Jain conducted a post mortem on Mr Pelle and opined that he died from epilepsy and that a right frontal lobe epidermal cyst was a significant condition contributing to his death, but not the disease or condition causing Mr Pelle's death. Associate Professor Jain found that Mr Pelle had bitten his tongue and that there were petechial haemorrhages on the visceral pleura and pericardium, which strongly suggested Mr Pelle had died in the context of a seizure.


The Coroner concluded that Mr Pelle died as a result of sudden unexplained epilepsy (SUDEP). The Coroner considered an expert review by Dr Ross Mellick, a Consultant Neurologist, of the care and treatment received by Mr Pelle at TCH on 25 July 2016. The report concluded:

  • Mr Pelle should have had other investigations performed at TCH on 25 July 2016;
  • the clinical features of Mr Pelle's patient history would have and should have justified a hospital admission;
  • it was not possible at the time of assessment to have determined that Mr Pelle would die the next day however, a scan may have identified other information and pointed towards admission, which may have avoided the fatal outcome;
  • if Mr Pelle had been in hospital an immediate response to the occurrence of a seizure may have enabled resuscitation and saved him; and
  • the failure to perform a non-contrast CT scan was outside the bounds of accepted medical practice and constituted wrong management.

On the basis of the expert review, the Coroner concluded that the failures outlined by Dr Mellick did not amount to a matter of public safety. However, the Coroner concluded that the care and treatment of Mr Pelle during his visit to TCH on 25 July 2016 was not of an appropriate standard.

The Coroner did not consider Mr Pelle's treatment demonstrative of a systemic or fundamental flaw in TCH's practices or processes however, the Coroner considered it appropriate to refer Mr Pelle's treating doctors to the Medical Board via the Australian Health Practitioners Regulatory Agency (AHPRA).


The Coroner did not consider a public hearing in relation to Mr Pelle's death necessary. The Coroner recommended that a referral be made to the AHPRA in respect of the doctors involved in treating Mr Pelle at TCH on 25 July 2015 and that AHPRA and TCH be provided with the autopsy report, the police report and Dr Mellick's report in relation to Mr Pelle.