AC-2024-LON-002499 - [2025] EWHC 2131 (Admin)

I take the facts from the Summary of Facts and Grounds (“SFG”) and pay tribute to the claimant’s legal team for the carefully crafted document.

On 14 January 2020, M was admitted to the Emergency Department of Royal London Hospital after he lost consciousness and collapsed in the street. The cause of the fall was never diagnosed and M was discharged from the hospital after a CT scan showed no intracranial pathology or haemorrhage.

On 19 August 2020, at approximately 06:56, M had another fall in the street following a loss of consciousness in similar circumstances to the incident on 14 January 2020. The London Ambulance Service (“LAS”) records note that M had potentially suffered an alcohol withdrawal seizure. At approximately 07:55, M was admitted to the Accident and Emergency department at Homerton Hospital. He gave a history of walking back from the shops, his legs feeling shaky and blacking out. At 08:55, following a consultation with Dr Champion and then Dr Radford, M had a CT scan which indicated no intracranial haemorrhage. He was noted to have a large midline parietooccipital scalp haematoma which required cleaning only. It was noted in the records that this fall was likely “ETOH withdrawal seizure”, that is ethanol (alcohol) withdrawal seizure.

At 09:37, M was discharged and left Homerton Hospital. At 10:19, paramedics attended M for a second time that day following a call from a member of the public who witnessed M fall again in the street. At 10:55, M was taken back to Homerton Hospital by LAS. M was noted to have been drinking: he was holding a can of open beer and was confused and unsteady on his feet. It was noted by Dr Radford that the wound on the back of his head was “now bleeding heavily” and required suturing. A further CT scan was conducted and it was reported by Dr Boavida that “comparison is made with the CT of 0855 19/08/2020. No interval change in the appearances. No intracranial haemorrhage.”

M stayed in hospital overnight for observation, but on the morning of 20 August 2020, he absconded and went to his sister’s house in his hospital gown. He was referred for psychiatric assessment. At 14:59, Dr Chloe Beale recommended that M be detained under the MHA 1983 following her assessment. Dr Beale stated in evidence that M was suffering from alcohol withdrawal symptoms at the time of this assessment and that she was concerned about this.

At 15:40, Dr Keyhani and Michael Jeggo conducted a second assessment of M and at 16:20, Dr Keyhani recommended he be detained under section 2 of the MHA 1983. Arrangements were made for his involuntary admission to Mile End Hospital which falls under the Trust. A copy of the discharge summary from Homerton Hospital, stated that the cause of M’s fall was “likely ETOH withdrawal seizure.”

At Homerton, there was a partially conducted CIWA (alcohol withdrawal assessment tool) which resulted in a score of 26. The recognised weighting of this score suggests that M was in severe withdrawal. Dr Felinski’s evidence was that a symptom or consequence of severe alcohol withdrawal could be seizures. Ms Olawale confirmed in her evidence that had M been able to engage fully with this assessment, his CIWA score could have been higher.

During the day, there was increasing concern about M’s condition. Eventually, at 19:22 M was taken by ambulance to Royal London Hospital, arriving at 19:57. A CT scan performed at Royal London Hospital at 20:19. It showed that M had suffered an acute subdural haematoma, small volume subarachnoid and intraventricular haemorrhage. It was also noted that the haematoma at the back of M’s head had expanded. Doctors concluded that M had suffered a brain injury that could not be survived.

On 26 August 2020, at 17:27, a formal brain stem test confirmed that M had suffered hypoxic ischemic encephalopathy resulting in an irreversible loss of brain stem function. His time of death was recorded as 17:27 on 26 August 2020.