QB-2022-002447 - [2025] EWHC 2803 (KB)

The Claimants say that some two years before the index attack, C3 had begun to exhibit signs of significant psychiatric illness. Through December 2016 and in October 2017 there were a number of visits to his GP and to Northwick Park Hospital, then on 11 November 2017, the police were called to the family home following a violent episode by C3 while at a family party during which he also tried to self-harm. C3 was taken to Northwick Park Hospital where it was concluded he had capacity, and so did not require admission. 

 On 12 November 2017, a referral was made to “Safeguarding Adults (Harrow)”, operated by D1, to which it is said no response was received.  During 2017 and into January 2018 C3 had further visits with his GP saw a life coach and hypnotherapist as well as a private psychiatrist. On 25 April 2018, that psychiatrist saw C3 for a second time and found him in the middle of a psychotic episode with probable thought disorder. On 14 May 2018, he prescribed Aripiprazole, an anti-psychotic, to C3.  

Between June and July 2018, C3 became increasingly violent and hostile. On 9 August 2018,  the same psychiatrist assessed C3 as detainable under the MHA, and the next day contacted D2’s Single Point of Access (“SPA”) mental health contact and C3 was referred to D2’s Crisis  Resolution and Home Treatment Team (“Harrow CRT”) the same day.  The records show that Harrow CRT made numerous notes. The Claimants rely on one in particular made by a Registered Mental Health Nurse attached to Harrow CRT that the plan would be to admit C3 voluntarily for short-term treatment and if not, carry out a Mental Health Act assessment. On 1 August 2018, this nurse referred the case to the duty AMHP (not the AMHP here) to arrange an urgent assessment. The Claimants say this was not actioned, rather, the nurse and a support worker visited the family home to carry out an informal assessment. On the same day, the nurse requested an urgent assessment on the basis of a perceived high level of risk posed by C3.

At about 6 PM on 11 August the registered mental health nurse attached to D1 referred the case to the duty AMHP (not the AMHP here) to arrange an urgent assessment. No action was taken on the referral, but the family was visited in order to assess C3. The registered mental health nurse concluded there was a high risk to family and a formal assessment under the MHA was required. He listed a number of features of concern. However C3 refused the voluntary admission. It was advised the police were contacted if he became aggressive again. A formal NHS assessment was requested on the basis that C3 was not suitable for community support. A few days later the urgent assessment was downgraded to a “planned assessment” as it was deemed not to be urgent by a Staff Nurse. 

On 12 August 2018, following a telephone update between a staff nurse attached to Harrow CRT and C1, the request for an urgent assessment was downgraded to a referral to the Harrow West Community Mental Health team.  The next day, C3 became increasingly aggressive pushing C1 to the floor and threatening to drop/throw a sofa footrest at her.   C1 telephoned the SPA in the early evening, but the student nurse present stated they were unable to help, as a doctor and an AMHP had not yet been appointed to carry out any assessment. C1 was again advised to contact the police or emergency services if she felt unsafe. Late in the same evening C1 called the police saying she was in fear of immediate unlawful violence and C3 was threatening to kill himself.