Author and Publication
Author: Ben Slater, Registered Social Worker, Founder and Managing Director of Nellie Supports
Reviewed by: Kerry Slater, Director of Operations
Last reviewed: 20 July 2026
Citation
1. Department of Health and Social Care (2022) National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care. Available at: https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-and-nhs-funded-nursing-care
2. Department of Health and Social Care (2022) NHS Continuing Healthcare Fast Track Pathway Tool.
3. Department of Health and Social Care (2022) NHS Continuing Healthcare Decision Support Tool.
4. R v North and East Devon Health Authority, ex parte Coughlan [2000] 2 WLR 622.
Copywright
Copyright © 2026 Nellie Supports Ltd. All rights reserved.
This article is made available for general information, education and professional reference. It may be downloaded, printed and shared for non-commercial purposes, provided that it is reproduced in full, is not altered in any way, and is properly cited as the work of Nellie Supports Ltd. This material must not be edited, adapted, sold, republished, incorporated into commercial products, or used for commercial training, assessment, report-writing or advisory services without prior written permission from Nellie Supports Ltd.
This article does not constitute legal advice, clinical advice or a substitute for a decision-specific professional assessment. Where legislation, government guidance, court forms or external professional materials are referred to, those materials remain subject to their own copyright, licensing and re-use terms.
Abstract
This guide explains the altered states of consciousness domain of the NHS Continuing Healthcare Decision Support Tool. It covers episodes of reduced or lost consciousness, seizure activity, hypoglycaemic and other metabolic episodes, the intervention required during and after an episode, why the domain carries a priority level, and the evidence that supports an accurate level.
The altered states of consciousness domain in the CHC Decision Support Tool
This domain covers episodes where consciousness is reduced or lost, most commonly seizures. It is one of only four domains that can reach priority, and it is heavily driven by how unpredictable the episodes are.
What the domain covers
Episodes of altered, reduced or lost consciousness, including epileptic seizures of all types, syncope, hypoglycaemic episodes, and episodes arising from other metabolic or neurological causes. It covers the frequency and duration of episodes, the intervention required during and after them, and the monitoring required to keep the person safe.
Why it can reach priority
The domain carries a priority level, alongside behaviour, breathing and drug therapies and medication. That reflects the immediacy of risk when consciousness is lost without warning, since injury, airway compromise or prolonged seizure activity can follow within moments. A single properly evidenced priority level would be expected to indicate a primary health need.
Frequency and unpredictability
Two factors drive the level. The first is how often episodes occur. The second, and often more significant, is how much warning there is. Episodes without any prodrome, occurring at any time of day or night, requiring someone competent to be immediately available, engage unpredictability in the four key characteristics analysis more strongly than almost anything else in the tool.
Intervention during and after
Record what is actually required. That may include positioning, airway management, oxygen, timed observation, rescue medication such as buccal midazolam, and the decision making involved in when to administer it or call for emergency help. Post-episode care matters too, including the recovery period, confusion, injury risk and the supervision required afterwards.
The well-managed need point
Seizures controlled by a finely balanced medication regime remain a significant need. Where control depends on precise timing, close monitoring and rapid adjustment, the record should describe the underlying instability and the regime maintaining control, not simply note that seizures are well controlled. This is one of the clearest applications of the principle in the whole tool.
Evidence that helps
Seizure diaries and charts, epilepsy nurse and neurology letters, rescue medication protocols and records of administration, records of emergency service attendance and hospital admission, injury records following episodes, blood glucose monitoring where relevant, and night time observation records. Records of any period when a regime was disrupted are particularly valuable.
Key takeaway
This domain can reach priority and is heavily driven by unpredictability. Record frequency, warning, the intervention required during and after episodes, and the regime maintaining any control, rather than recording that episodes are currently well managed.
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Frequently asked questions
Can this domain reach priority?
Yes. It is one of four domains carrying a priority level, alongside behaviour, breathing and drug therapies and medication. A single properly evidenced priority level would be expected to indicate a primary health need.
Seizures are controlled, does that mean no need?
No. Control achieved through a finely balanced regime and close monitoring is a managed need, not an absent one. Record the underlying instability and what maintains control.
Do infrequent seizures count?
Yes. Infrequency with no warning goes directly to unpredictability, which is one of the four key characteristics. Record how much warning there is and what the consequences are when an episode occurs.
Related NHS Continuing Healthcare pages
These links take you to the most relevant Nellie Supports service page and to the supporting guides that explain the surrounding process.
Speak to an independent CHC specialist
Nellie Supports prepares independent needs evidence for NHS Continuing Healthcare assessments, reviews and appeals across England and Wales. Our reports are written by registered social workers on a permanent employed team, with internal peer review before release. Call 0333 987 5118 or send an enquiry and we will talk through where you are in the process.