Ali, R (On the Application Of) v HM Assistant Coroner for Inner North London

Factual and Procedural Background

This opinion concerns a renewed application for permission to proceed with a judicial review challenging the coroner's ruling that Article 2 of the European Convention on Human Rights was not engaged. The claimant is the sister of the deceased, who suffered cardiac arrest while an involuntary inpatient detained under section 2 of the Mental Health Act 1983 at Mile End Hospital. The deceased had a history of falls and alcohol withdrawal symptoms prior to admission. The defendant is HM Assistant Coroner for Inner North London, with two NHS Foundation Trusts as interested parties. Permission was initially refused by Turner J, and judgment was reserved for further consideration of the submissions and materials.

On 14 January 2020, the deceased was admitted to Royal London Hospital after losing consciousness and collapsing, with no intracranial pathology found. On 19 August 2020, he suffered two falls in the street, likely due to alcohol withdrawal seizures, with head injuries documented but no intracranial haemorrhage detected on CT scans. He was admitted and discharged from Homerton Hospital on the same day, then readmitted following a third fall with a bleeding head wound. He was detained under the Mental Health Act and admitted to Mile End Hospital on 20 August 2020. During his detention, concerns arose about his alcohol withdrawal severity and risk of seizures, but monitoring and assessments were incomplete or deficient.

On 21 August 2020, the deceased was found non-responsive on the floor of the ward with bleeding to the head. Subsequent scans revealed an acute subdural haematoma and brain injury deemed unsurvivable. He died on 26 August 2020.

Legal Issues Presented

1. Whether the coroner's ruling that Article 2 of the European Convention on Human Rights was not engaged was arguable and lawful.
2. Whether there was a foreseeable significant or substantial present and continuing risk to the deceased's life during his detention that engaged the positive operational duty to protect life.
3. Whether the Trust failed to take reasonable protective or preventative measures that could have averted or substantially reduced the risk to life, thereby breaching the positive obligation under Article 2.

Arguments of the Parties

Appellant's Arguments

• The claimant relied on the deceased’s history of falls likely caused by alcohol withdrawal seizures and head injuries sustained prior to detention.
• The Trust was aware of the risk and instructed close monitoring for alcohol withdrawal symptoms, yet monitoring and risk assessments were inadequate or absent.
• The claimant submitted that the deceased likely suffered an additional unwitnessed fall while under hospital care, evidenced by his changed position, incontinence, and subsequent head bleeding.
• Failures included absence of risk assessments, care plans, proper monitoring, adherence to hospital policies, and adequate staffing and training.
• These failures collectively deprived the deceased of a substantial chance to avoid the fatal injury, engaging the positive duty under Article 2 as established in relevant case law.

Table of Precedents Cited

Court's Reasoning and Analysis

The court divided the analysis into two main parts: (1) whether the Trust failed to take reasonable measures to protect the deceased's life, and (2) whether there was a foreseeable significant or substantial present and continuing risk to life.

Regarding failure to take reasonable measures, the court applied the causation standard from Van Colle and Savage, requiring proof that the deceased lost a substantial chance of avoiding death due to the Trust's failures. The evidence that the fatal injury resulted from an unwitnessed fall while under hospital care was speculative and did not rise above a possibility. The medical evidence did not conclusively link the injury to a hospital fall, and the alleged failures could not be clearly connected to depriving the deceased of a substantial chance to avoid death. Consequently, this ground was found not arguable.

On the risk to life, the court emphasized the stringent operational duty standard requiring a real and immediate risk to life, not merely a risk of serious injury. Although the deceased was at risk of seizures and serious injury due to alcohol withdrawal, the evidence did not establish a substantial present and continuing risk to his life once detained and observed. The previous CT scans were unremarkable for intracranial bleeding, and the risk of death was not sufficiently foreseeable or immediate to engage Article 2 protections. The coroner's decision was therefore neither irrational nor unlawful.

The court further noted that factual findings by the coroner, made after an extended inquest with live evidence, did not reach the threshold of arguable irrationality.

Holding and Implications

The court REFUSED PERMISSION to proceed with the judicial review challenging the coroner's ruling on Article 2 engagement.

The direct effect is that the coroner's conclusion that the positive operational duty under Article 2 was not engaged stands. The claimant's challenge based on alleged failures and risk to life was found unarguable due to speculative causation and insufficient evidence of a substantial and immediate risk to life. No new legal precedent was established by this decision. The coroner remains the appropriate authority to make factual determinations in such inquests.