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MRCGP SCA course · Station 17
Station 17 · After a seizure
A 58-year-old delivery driver had a first seizure three weeks ago; he has his van keys in his hand and does not think the DVLA advice applied to a “one-off”.
Reviewed and kept current
Video consultation · Professional conversation · Undifferentiated presentation · Health disadvantage and vulnerabilities · 12-minute case · 3 min reading · Last editorial review: 11 October 2026 · Next scheduled refresh: 11 April 2027 · Clinical content signed by Course Director, 11 October 2026.
Candidate instructions
Read this as you would outside the room
Read the brief as you would in the examination (RCGP: twelve consultations with simulated patients, each lasting twelve minutes, with 3 minutes' reading at the start of each). There is no reference material. Everything below the brief is folded until the consultation is over.
| Information | |
|---|---|
| Frame | You have 3 minutes to read, then 12 minutes. Video consultation. Everything below this brief is folded away until the consultation is over. |
| Your role | GP partner at a town practice. The practice asked him to book this follow-up after the hospital letter. |
| Patient | Lee Baxter, 58. |
| Reason for consultation | Follow-up after the emergency department, booked at the practice's request. |
| Format | Video. He is in his kitchen; you can see his face and hands. You cannot examine him; the hospital findings are in the record. |
Information available
The records extract, printed as it appears.
| Problem list | Hypertension. Alcohol recorded at 15 units a week. Employed delivery driver (3.5-tonne van). |
| Medication | Amlodipine 5 mg daily. Allergies: none recorded. |
| Emergency department letter, 3 weeks ago | Witnessed generalised tonic-clonic seizure at home; first ever. CT head: normal. Bloods: normal. ECG: normal. Advised must not drive and to inform the DVLA. First-fit clinic referral made: appointment in 6 weeks. No anti-seizure medication started. |
| Since then | No entries. |
Your task
•
Review what happened and assess him since.
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Reach a working diagnosis, with the alternatives you have considered.
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Agree a plan with him, including driving and work.
•
Address his concerns.
Folded away
For the role player and the observer
Open these after the consultation, or during it if you are observing. The role-player script and every marking section are public (D-76): this is practice material, not an examination.
1 · Role-player script — opening line, story, ICE, hidden facts and triggers (examination findings last)
Candidates: do not open until you have consulted.
Persona and manner
- Lee Baxter, 58, a delivery driver for a courier firm for fifteen years; pleasant, evasive, keys in your hand; you tense when driving is raised; anger flares once, then honesty.
- You have decided it was a one-off caused by heat and beer, and you have been driving for work for two weeks.
Opening line (verbatim)
- “Thanks for seeing me — I'm fine now, the hospital said the scan was clear. I just wanted to check there's nothing else I need to do before the clinic.”
The story
- “A one-off. Probably the heat, and I'd had a few beers the night before. I was back at work the next week.”
- If asked: no further fits. Your wife found you on the kitchen floor shaking, you had bitten your tongue and wet yourself, and you were confused for twenty minutes. You remember nothing.
- If asked about earlier events: “A couple of moments where I lose a few seconds. Everyone does that.” Blank spells over the past year, once while stationary in the van; your wife has said “you went off again” three or four times this year; a colleague once had to repeat a delivery address twice.
- No jerks that you have noticed; sleep poor; alcohol 15 to 20 units, a few pints most evenings, more at weekends, “never at work”; no drugs; no head injury; no family history.
- If asked directly whether you are driving: “I've got to. It's my job.” The hospital mentioned the DVLA “but I didn't think it applied to a one-off”. You have not told the DVLA or your employer.
- Two months' savings; a mortgage; your wife works part-time; grown-up children; “I've driven all my life”; your manager “would let me go”; a points system for lateness; you believe the manager “has it in for the older drivers”.
- If asked about safety at work beyond driving: you load at height sometimes.
Ideas, concerns and expectations
- Idea: “A one-off from beer and heat.”
- Concern: Losing the job; “being labelled epileptic”.
- Expectation: Reassurance and no restrictions.
Impact
- Work: the company van; fifteen years; the manager; the points system.
- Money: two months' savings; the mortgage; your wife's part-time wage.
- Home: your wife is frightened; she has not said so to you.
Red flags
- Present: Driving for work after a first seizure with the DVLA not notified; possible earlier absences over a year, including one in the van; loading at height; alcohol above the low-risk level.
- Absent: No further generalised seizures; a normal scan, bloods and ECG; no head injury; no focal symptoms.
Hidden facts and their triggers
- That you are driving, for two weeks — released only only if asked directly whether you are driving; “I'm fine now” is not an answer to that
- The blank spells and your wife's “you went off again” — released only if asked about any earlier odd episodes, moments of lost time or your wife's observations
- The loading at height — released only if asked about safety at work beyond driving
- The savings, the mortgage and the manager — released only if asked what stopping driving would mean
- That you would stop if given both the law and a plan for the money — released only only after honesty about both
Behaviour
- Minute 1: the keys; “I'm fine now.”
- Minute 3: “I didn't think it applied.”
- Minute 5: “My manager would let me go.”
- If the doctor draws out the picture including the blank spells, explains clearly and kindly that after a first seizure you must not drive and must tell the DVLA, explains the doctor's own duty if you keep driving as a fact and not a threat, explores the money and offers practical help (a note for non-driving duties, a letter for the employer with your consent, benefits signposting), addresses the drink, offers to write to the clinic about the blank spells, checks you have understood and agreed, and follows up in two weeks: angry (“You're joking”), then quiet (“And if I keep driving?”), and when answered honestly: “OK. Can you write something for work?”
- If the doctor says it is your decision, or accepts “one-off”: relieved. Leave.
- If the doctor threatens without support (“I'll have to report you”): “Do what you like.” Disengage unless the doctor recovers.
- If the doctor uses the word epilepsy as a label without explaining: tense; “So I'm epileptic now?”
Examination findings, if the candidate states what they would examine and why
- Video: no examination today. If the candidate states what they would examine and why: you look well; no tongue injury now; blood pressure at the pharmacy last week 144/88; the hospital's neurological examination was normal.
2 · Examiner mark sheet — generic SCA scheme plus the key facts for this case
Domain grades — with the key facts that earn a clear pass at this station
| Domain (RCGP wording) · key facts for this case | CF (0) | F (1) | P (2) | CP (3) | Score |
|---|---|---|---|---|---|
1 · Data gathering and diagnosis
| ☐ | ☐ | ☐ | ☐ | /3 |
2 · Clinical management and medical complexity (×1.5)
| ☐ (0) | ☐ (1.5) | ☐ (3) | ☐ (4.5) | /4.5 |
3 · Relating to others
| ☐ | ☐ | ☐ | ☐ | /3 |
| Case total | /10.5 |
Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass
The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.
The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.
Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”
3 · Expanded station standard — what earns a clear pass, pass, fail and clear fail here
Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.
| Grade | Data gathering and diagnosis | Clinical management and medical complexity | Relating to others |
|---|---|---|---|
| CP | Asks in the first two minutes whether he is driving, in those words, and takes the keys in his hand as the answer before he gives it. Goes looking for earlier events with specific questions and reasons aloud that blank spells over a year change what the clinic is looking at. Counts the alcohol. Asks what the DVLA advice meant to him and what stopping would cost, so that the refusal is understood before it is met. | States the rules accurately and in full: must not drive now, must notify the DVLA, six months off after a first seizure with normal investigations and no recurrence, longer if the risk is higher; a 3.5-tonne van is a car licence. Explains the duty to disclose if he continues as a fact, with the steps that come first. Writes to the clinic about the blank spells. Offers the note, the employer letter and benefits signposting. Review in two weeks. | Names the dilemma openly: the doctor would rather help him keep his livelihood than report him, and will report him if he keeps driving. Allows the anger and does not match it. Answers “labelled epileptic” factually and without the label. Treats the money as a real problem with real options rather than a reason to collude. Explains how the licence comes back, to give hope. Checks that he has understood and what he has agreed. |
| P | Takes the seizure history and asks about earlier events (absences, jerks, night events). Asks about provoking factors, alcohol and sleep. Establishes explicitly that he is driving, his occupation and the van's weight, his understanding of the DVLA advice and whether the employer knows. Uses the hospital letter and recognises that the clinic has not yet seen him. Working diagnosis: a first generalised seizure, with possible earlier absences to be reported to the clinic. | Gives clear advice: must not drive; must notify the DVLA; after a first unprovoked seizure, six months off if investigations are normal and no recurrence, twelve months if the risk is higher; the van follows the car rules. Documents the advice. Explains the GMC duty: if he continues to drive, the doctor will tell the DVLA after trying to persuade him. A fit note for non-driving duties, an employer letter, benefits signposting; alcohol reduction; review in two weeks. | Honest, direct and non-punitive from the first mention of driving. Explores the fear of losing work and responds practically, with the note and the letter rather than sympathy alone. Separates the law from the doctor's regard for him and owns the duty as his own rather than someone else's rule. Allows the anger without matching it; checks understanding and agreement before the call ends. |
| F | Accepts “one-off” and does not ask whether he is driving. Ignores or does not look for the earlier events. Does not count the alcohol or ask about sleep. Does not ask what the DVLA advice meant to him or what stopping would cost. Does not use the hospital letter. | Says it is his decision. Or gives the DVLA rules incorrectly, or not at all. Or threatens to report him without the steps that come first and without any support. No note, no employer letter, no benefits signposting. The clinic not told about the blank spells. No documentation. No review. | Lectures. Colludes to avoid the conflict. Vague about the duty, or uses it as a threat. Dismissive of the money. Uses epilepsy as a label without explanation. Does not allow the anger or hear what is behind it. Ends without knowing whether he will drive tomorrow. |
| CF | No enquiry about driving in a professional driver three weeks after a seizure; no search for earlier events; the alcohol not asked about; the letter not read. Or a consultation in which the keys in his hand are never noticed and the question is never asked. | Unsafe: a professional driver told it is his decision, or told nothing about the DVLA, or reassured that a one-off needs no restriction; or threatened so that he disengages and keeps driving with no support and no documentation. He leaves to drive the van tomorrow. | Punitive, dismissive of fifteen years and a mortgage, or collusive to keep the peace; the anger met with anger or with a shrug; no honesty about either the law or the consequences, and no attempt to find out what stopping would cost him. No partnership and a decision he will make alone, badly. |
Where candidates lose this station
- Accepting “I'm fine now” and never asking in plain words whether he is driving, so that the keys in his hand are never explained (statement D1)
- Telling him it is his decision, or giving the DVLA rules wrongly, so that he drives the van tomorrow believing the doctor agreed (statement C5)
- Threatening to report him before explaining the rules or offering any help with the money, so that he says “Do what you like” (statement R5)
What the examiner is listening for in the last four minutes
By 8:00 the working diagnosis should have been stated: a first generalised seizure, with possible earlier absences that the clinic needs to know about. The examiner is listening for: must not drive and must notify the DVLA, with the rules stated accurately and documented; the doctor's duty if he continues, explained as a fact with the steps that come first; the practical plan for work and money; the letter to the clinic about the blank spells; the alcohol and the safety advice; a safety-net for a further seizure; the review in two weeks; and his own words on what he will do about the van tomorrow.
4 · RCGP feedback statements — where underperformance was identified — with case-specific examples
The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.
| RCGP feedback statement (postulated top ten) | Underperformance it signals (generic) | Station-specific example |
|---|---|---|
| D1 · Data gathering was insufficient to enable safe assessment of the condition/situation Data gathering and diagnosis · Data gathering and interpretation | History too thin to decide safely: the presenting problem not characterised, the essential negatives not asked. |
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| D2 · Existing information about the case was insufficiently utilised Data gathering and diagnosis · Data gathering and interpretation; Organisation, management and leadership | The records, results or the referral note not read or not used; questions asked that the notes already answer. |
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| D6 · The implications of relevant findings identified during the data gathering were insufficiently recognised or understood Data gathering and diagnosis · Data gathering and interpretation | A finding or result is elicited but its meaning is not recognised or not followed up. |
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| D7 · Differential diagnoses or hypotheses were inadequately generated or tested Data gathering and diagnosis · Making diagnosis/decisions | One diagnosis assumed; alternatives not generated, or generated but not tested with a question. |
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| C1 · The management plan relating to referral was inappropriate or not reflective of current practice Clinical management and medical complexity · Clinical management | Referral made when not indicated, omitted when indicated, or to the wrong service or urgency. |
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| C5 · The plan relating to the medical management of risk was inadequate or inappropriate Clinical management and medical complexity · Clinical management; Organisation, management and leadership | Clinical risk left unmanaged: no plan for the thing that could go wrong, or the risk not weighed. |
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| C8 · Inappropriate or inadequate arrangements for follow-up, continuity and/or safety netting Clinical management and medical complexity · Clinical management | No follow-up, continuity or safety-net, or one too vague to act on. |
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| R1 · Communication skills, including the non-verbal, responding to cues and/or active listening were insufficiently demonstrated Relating to others · Communication and consultation skills | Cues missed; the patient interrupted; non-verbal signals ignored; questions read like a form. |
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| R5 · A judgemental approach was shown to the person Relating to others · Communication and consultation skills; Maintaining an ethical approach | Disapproval, moralising or blame shown in words or manner. |
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| R7 · Ownership or responsibility for decision-making was inadequate or inappropriate Relating to others · Fitness to practise; Making diagnosis/decisions; Maintaining an ethical approach | Decisions deferred, delegated or left to the patient when the doctor should own them. |
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The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.
- After a first unprovoked epileptic seizure, a Group 1 driver (car and motorcycle; a van up to 3.5 tonnes) must not drive and must notify the DVLA; the licence is usually restored after six months free of further seizures if investigations show no abnormality that increases the risk of a further seizure, otherwise after twelve months. DVLA — Assessing fitness to drive: neurological disorders, epilepsy and seizures: first unprovoked seizure, Group 1, 2024 edition, checked 10 Oct 2026
- Where a patient has a condition that may affect their fitness to drive, explain that the condition may affect their ability to drive and that they have a legal duty to inform the DVLA; if the patient continues to drive when they are not fit, make every reasonable effort to persuade them to stop; if they cannot be persuaded, or there is evidence that they are continuing to drive, contact the DVLA and disclose the relevant information, telling the patient before and after. GMC — Confidentiality: patients' fitness to drive and reporting concerns to the DVLA or DVA, paragraphs 1 to 10, 2017, checked 10 Oct 2026
- Refer anyone with a first suspected epileptic seizure to be seen by a specialist within two weeks; a history of earlier episodes such as absences, myoclonic jerks or focal symptoms is relevant to the diagnosis and should be sought and passed to the specialist; a witness account is essential. NICE — NG217 Epilepsies in children, young people and adults, section 1.1, diagnosing epilepsy; section 1.2, referral, 2022, last updated October 2025, checked 10 Oct 2026
- Anti-seizure medication is not usually started after a single unprovoked seizure in primary care; the decision follows specialist assessment, which may include an EEG and MRI, and is made with the person according to their risk of recurrence and their circumstances. NICE — NG217 Epilepsies in children, young people and adults, section 1.3, investigations; section 2.1, principles of treatment, 2022, last updated October 2025, checked 10 Oct 2026
- Safety advice after a seizure includes not bathing alone (showers preferred), avoiding heights, open water and dangerous machinery until assessed, and what others should do during a seizure; call 999 for a seizure lasting more than five minutes, a second seizure without recovery, or injury. NICE CKS — Epilepsy, management: safety advice; when to call emergency services, current online version, checked 10 Oct 2026
- Alcohol excess and alcohol withdrawal are provoking factors for seizures and lower the seizure threshold; the UK Chief Medical Officers' low-risk guideline is not more than 14 units a week spread over three or more days. NICE CKS (citing the UK Chief Medical Officers' 2016 guideline) — Alcohol, problem drinking, background: the low-risk drinking guideline and unit calculation, current online version, checked 10 Oct 2026
- A fit note can state that the person may be fit for work with adjustments such as amended duties; a driver who must not drive can be certified as fit for non-driving duties, and the employer decides whether the adjustment can be made. GOV.UK (DWP) — Getting the most out of the fit note: guidance for healthcare professionals, may be fit for work; adjustments, 2022, updated 2024, checked 10 Oct 2026
- A licence holder who becomes aware of a relevant disability, or a condition likely to become one, must notify the DVLA at once; a seizure is such a condition. A driver who does not tell the DVLA about a condition that affects driving can be fined up to 1,000 pounds and may be prosecuted if involved in an accident; motor insurance may also be invalid. GOV.UK (DVLA) — Medical conditions, disabilities and driving, telling DVLA about a medical condition; penalties, current online version (Road Traffic Act 1988, section 94), checked 10 Oct 2026
- Group 2 entitlement (lorries over 3.5 tonnes and buses) is stricter: after a single unprovoked seizure the licence is refused or revoked and relicensing is considered only after five years free of seizures without anti-seizure medication, longer where investigations show a continuing risk. A seizure that followed drinking is not treated as provoked; provoked seizures are those with a clear, non-recurring precipitant such as an acute head injury. DVLA — Assessing fitness to drive: neurological disorders, epilepsy and seizures: first unprovoked seizure; provoked seizures; Group 2 standards, current online version, checked 10 Oct 2026
- Give information about sudden unexpected death in epilepsy (SUDEP) and how to reduce the risk, together with first-aid and safety information, to the person and their family after a seizure. Risk is higher with generalised tonic-clonic seizures, seizures during sleep, poor adherence to anti-seizure medication and living or sleeping alone; the discussion is recorded, and a seizure diary and a witness account help the specialist. NICE — NG217 Epilepsies in children, young people and adults, section 1.5 (information and support): risk of SUDEP; safety, NG217, 2022, checked 10 Oct 2026
- Use a validated tool such as AUDIT to assess the pattern of drinking; a score of 8 or more indicates hazardous or harmful drinking and the person is offered structured brief advice, with referral where the score suggests dependence. Twenty units a week with drinking most evenings is above the low-risk level, and the advice links the alcohol to the seizure, the sleep and the blood pressure. NICE — PH24 Alcohol-use disorders: prevention, recommendations on screening and brief interventions in primary care, PH24, 2010, checked 10 Oct 2026
- Information for an employer is shared only with the patient's consent and limited to what the employer needs: a fit note or a letter stating that the person is not permitted to drive for a period and may be fit for other duties. The doctor does not disclose the diagnosis to the employer without consent, and tells the patient what the letter will say before it is sent. GMC — Confidentiality: good practice in handling patient information, disclosures with consent; disclosures to employers and insurers, 2017 (in force 2018), checked 10 Oct 2026
- The curriculum expects the GP to manage a first seizure: to take a witness history, to identify provoking factors including alcohol, to refer to a first-seizure service, to give accurate advice on driving and the DVLA rules for the licence the person holds, to advise on safety at work and at home, and to act on the duty to disclose where a patient continues to drive against advice. RCGP — GP curriculum: Neurology, epilepsy and first seizure; driving regulations and fitness to work, Being a GP, 2025 curriculum, checked 10 Oct 2026
Working references for this station
13 statements, 754 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.
This case's topic and its signed Golden Triangle, for review after the station.
Golden Triangle
First seizure and epilepsy in adults
Knowledge Amber · Evidence Amber · Real-world Red
Not yet at the Equinox · UK (NHS England) · as of 8 October 2026 · How the triangle works
6 · RCGP curriculum tags for this case
| RCGP curriculum (2025) | This case |
|---|---|
| Topic Guide(s) | Neurology · Leadership, management and administration · Smoking, alcohol and substance misuse |
| Core capabilities | An ethical approach · Communicating and consulting · Decision-making and diagnosis · Fitness to practise |
| SCA Clinical Experience Group(s) | Professional conversation / Professional dilemma · New presentation of undifferentiated disease · Health disadvantage and vulnerabilities, including veterans, mental capacity, safeguarding, and communication difficulties |
| AKT blueprint clinical area | Neurology (moderate representation) |
| Case type | professional conversation |
| Modality | video |
7 · My marks and reflection — practice log form
Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.
Record my marks and reflection for SCA-17
Revision link for this case: mdacumen.com/sca-station17-seizure
Independence & scope. Formative training material from MD Acumen Ltd; not a prediction of exam performance. Not affiliated with, endorsed by, or delivered on behalf of the Royal College of General Practitioners; the marking domains and feedback statements are the RCGP's published ones, and every descriptor on this page is an Acumen training tool calibrated to them. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.
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