Those with established epilepsy frequently visit emergency departments (ED) for uncomplicated seizures. The ambulance service might be able to help reduce these. The service currently transports most seizure patients it sees to ED, despite clinical need often seeming to be lacking. Via semi-structured interviews with a purposive sample of 19 paramedics we explored why this might be. Participants were recruited from 5 (of the 11) ambulance services in England and the College of Paramedics. Data were analysed thematically. Participants’ highlighted how various factors, beyond clinical need, can influence their care decisions when managing seizures and mean conveyance to ED remains the default management plan. Factors included continued lack of access to patients’ medical histories, few alternative care pathways, time constraints, and limited seizure management training. Most were receptive to further training, providing content, format and delivery recommendations. Participants were particularly keen to learn how to better differentiate seizures and criteria for non-conveyance. A range of organisational, structural, professional, and educational factors may need to be attended to so as to reduce unnecessary conveyance of seizures. Our findings can be used to inform the development of seizure management training, which might ultimately benefit paramedic confidence and quality of patient care.