CW died on 26 January 2024, aged 38. The cause of death was acute drug intoxication.

During the postmortem, it was found that CW had secreted a package of cocaine. The inquest heard that it is likely that a fatal dose of cocaine escaped from that package.

On 25 January 2024, CW presented as highly distressed, exhibiting unusual and concerning behaviour at the family home. He was arrested and taken to St Helier Hospital (Epsom and St Helier University Hospitals NHS Trust). Police were informed that CW had been taking drugs and drinking. Police gave evidence that they informed healthcare staff of this information. The jury found that the collateral information regarding CW’s history of drug use was not shared between all shareholders.

CW’s self-harm wound was checked in A&E. A mental health assessment then took place, which lasted less than four minutes. CW was assessed as having no acute mental health concerns and was fit for custody. Mental health staff gave evidence that their practice of conducting assessments is far more limited for patients under arrest: either they are fit for custody or require a Mental Health Act assessment. South West London & St George’s Mental Health NHS Trust accepted the mental health assessment undertaken in the waiting room was inadequate.

It was discovered that CW was in fast atrial fibrillation and he was moved to resus at around 3am. Over the course of the early morning, CW experienced agitation and could hear people who were not there. At 09.30 CW became very distressed and agitated and had to be restrained by multiple officers.

CW refused to have scans and was distressed at the thought of being injected. Around this time, the treating doctor felt CW lacked capacity. No scans were undertaken.

CW began fitting between midday and 1pm, and eventually suffered a cardiac arrest. Doctors attempted to resuscitate CW. CPR was stopped at 14.26.

The jury found CW’s medical cause of death (cocaine intoxication) was not identified by treating clinicians prior to CW’s death. It appeared in evidence that CW was not asked about drug use or concealment in the absence of police officers while in resus. Further, CW’s family were not contacted to obtain any collateral information while he was alive. His partner and mother gave evidence that they would, if informed of CW’s symptoms and refusal of scans, have told clinicians of CW’s recent cocaine use and his history of secreting cocaine on his person.

The jury were not permitted to find that failings by healthcare professionals or police were causative of his death due to the medical evidence heard. They did, however, record the following non-causative failings (1) inadequate mental health assessment; (2) communication breakdown by all relevant stakeholders.

HM Coroner Professor Andrew Harris will be issuing a PFD on several issues arising from the inquest.

Isabel was instructed by Iftikhar Manzoor of Hudgell Solicitors.