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

Four key factors are relied on by the claimant in respect of risk to life:

In oral argument, Ms Maragh presented the court with a comprehensive factual history, commendably grounded in her command of detail. The essence of the submission is that one must combine the recent history of falling on 19 August with M’s presentation of obviously being unwell due to his mental health. For example, he absconded from the hospital with a canula in his hand and dressed in a hospital gown. When he was involuntarily detained, he was sedated and observed to be awake all night. He was monitored every 15 minutes as a new patient. At 14:00 the next day, he was noted to have changed a position with his trousers down and being incontinent of urine. This is said to be “indicative of the possibility of a fall”. It is submitted that the change of position provides some evidence of another fall. Sarah Thompson (lead nurse on Lea Ward) attended at 17:45 and saw him lying on the floor and non-responsive. He appeared to be bleeding to the back of the head. It is submitted that this suggests that somewhere between 14:00 and 18:00 he sustained another blow to the head from a fall. Evidence given at the inquest was to the effect that the haemorrhaging seen on 23 August was likely to have been caused by a fall after involuntary admission. Professor Thom’s evidence was that the most common cause of a subdural haemorrhage was a fall or a head injury. Thus on the evidence, the injury to his head was sustained while he was under the management and care of the Trust. M was a vulnerable person. Had he had been properly observed and monitored, it is likely he would have been safeguarded against a fall. This is the harm that likely led to his death and it could have been avoided but for the Trust’s collective failures. Therefore, there is sufficient evidence for the coroner to find that the test for the risk to life was met and clearly relevant operational failures in the Morahan sense (R (Morahan) v West London Assistant Coroner [2021] EWHC 1603 (“Morahan”)).

As to operative failures to take reasonable protective or preventative steps, the claimant relies on those factors identified in her SFG at para 77:

“It was also clearly arguable that there was a breach of the positive obligation given the hospital’s failure to take reasonable measures which might have averted and / or substantially reduced the risk to Mahamoud’s life, for the following non exhaustive reasons:

(a)

No risk assessment was undertaken on Mahamoud’s admission to Lea Ward at 18.40 on 20 August 2020 and throughout his time as a patient on the ward until up to 18.00 on 21 August 2020 when he was found in cardiac arrest. As a consequence there were no assessment of risk in relation to his head injury, or that associated with his alcohol withdrawal, risk of falls and of seizures;

(b)

There was no care plan for Mahamoud during his detention on the Lea Ward, contrary to the hospital’s own policy;

(c)

There was a failure to closely monitor Mahamoud following his restraint and the administration of rapid tranquilisation, contrary to the hospital’s policy;

(d)

There was a failure to follow the hospital’s policy on de-escalation in the first instance before restraint and in restraining him at 00:30 20 August placing him at risk of further head injury;

(e)

There was a failure to conduct any CIWA assessment between 18.40 on 20 August 2020 and 00.30 on 21 August 2020 despite the instructions on handover from Homerton Hospital and a further failure to follow up the partially completed CIWA assessment at 00.30 on 21 August 2020 despite the instructions of Dr Felinski and Dr Sessay. This left Mahamoud without any assessment or management of his alcohol withdrawal for approximately 18 hours when he was found in cardiac arrest;

(f)

Given Mahamoud’s history of falls and presenting head injury, there was a failure to assess whether he had sustained any further physical injuries or whether he suffered a fall when he was observed at 14.15 incontinent of urine with his trousers down to his ankles;

(g)

There was a failure to reassess Mahamoud’s physical condition and vital signs after 14.30 on 21 August 2020, taking in to account the possibility he had suffered a further fall and/or a seizure leading to a further fall;

(h)

There was a failure to conduct any observations at all between 16.45 and 17.45 which meant that there was no monitoring of his physical health during this time;

(i)

There were delays in providing Mahamoud with appropriate care at 17.45 on 21 August 2020

(j)

There was a failure to ensure that all staff were adequately trained in the relevant policies, including in particular the hospital’s observation policy; and

(k)

There as a failure to ensure adequate and safe staffing levels at Mile End Hospital.”