Atole Timothy Enaholo v Totally PLC & Anor

The claimant alleged clinical negligence in a misdiagnosis of psychosis, unlawful disclosure of medical records to his employer and unlawful disclosure to his general practitioner, and sought rectification of his records. The court found that the clinicians who examined the claimant on 30 June 2019 acted within acceptable professional standards in forming provisional views that his account of being irradiated was likely a delusion and that a formal Mental Health Act assessment might be required.

The court held there was no reliable evidence that the defendants disclosed the claimant's hospital records to his employer and declined to draw an adverse inference against absent NHS staff. Disclosure of the contemporaneous notes and the recommendation to the claimant's GP was, however, lawful and justifiable as being likely to facilitate the provision of health care and in the claimant's best interests under the duty identified with section 251B of the Health and Social Care Act 2012. The claim for rectification and for breach of data protection in respect of disclosure to the GP therefore failed. The claim is dismissed.

Background and parties: The claimant, aged 54, alleged that staff at Totally plc's Urgent Care Centre and at Imperial College Healthcare NHS Trust negligently misdiagnosed him with a psychiatric disorder on 30 June 2019, facilitated a Mental Health Act assessment referral, and unlawfully disclosed his medical records to his then employer (Peninsula) and to his GP. The defendants admitted care responsibility but denied negligence and asserted any disclosure to the GP was lawful.

Nature of the proceedings: Trial of liability only. The claimant sought damages for clinical negligence, breaches of the Data Protection Act 2018, and rectification of his records; if liability were established, causation and quantum would be tried later. The judgment resolves liability and closes the case.

Key facts:

• On 30 June 2019 the claimant attended the UCC and was later taken by ambulance to St Mary’s Hospital complaining of chest pain and reporting being targeted by police with microwave radiation. Routine tests were normal.
• Clinicians (triage nurses, two GPs/doctor assessors and psychiatric liaison nurses) recorded the claimant's account and formed provisional views that he displayed delusional beliefs and required psychiatric liaison assessment; the claimant declined formal psychiatric assessment and left voluntarily.
• Contemporaneous notes were sent to the claimant's GP including a recommendation to consider a Mental Health Act assessment in the community.
• The claimant alleged those notes, or a diagnosis of psychotic disorder, were disclosed to his employer causing loss of employment; no direct evidence of disclosure to Peninsula was produced.

Issues framed: (i) Whether clinicians were negligent in forming and recording a provisional diagnosis of mental disorder on 30 June 2019; (ii) whether there was unlawful disclosure of medical records to the claimant's employer; (iii) whether disclosure to the claimant's GP was unlawful; and (iv) whether rectification of the records was required.

Court's reasoning and conclusions:

• The court rejected the claimant's contention that diagnosis requires patient consent and accepted that provisional diagnostic views are within the competence of the clinicians involved. Given the claimant's presentation, sincere but unlikely assertions of electrosensitivity, and normal test results, it was reasonable and within professional standards for clinicians to suspect psychotic delusions and to seek psychiatric liaison assessment. The court therefore dismissed the clinical negligence claim.
• The claimant failed to prove on the balance of probabilities that the defendants disclosed his hospital records to his employer. The court would not draw an adverse inference against absent NHS witnesses because other plausible routes existed by which Peninsula could have learned of concerns (including the claimant's own prior communications). The allegation of unlawful disclosure to Peninsula therefore failed.
• The court accepted that the defendants did disclose their contemporaneous notes to the claimant's GP and held that disclosure was lawful and justified. In particular, the court considered that a duty to disclose arose under the principle reflected in section 251B of the Health and Social Care Act 2012, where disclosure is likely to facilitate provision of health services and is in the patient's best interests.
• There was no evidence of improper alteration of the records; coding additions were explained as routine. The claim for rectification was therefore dismissed.

The court concluded by dismissing the claim, entering judgment for the defendants on liability, and inviting draft orders to deal with costs and related matters.

The claim is dismissed. The court held that clinicians who saw the claimant on 30 June 2019 acted within acceptable professional standards in forming provisional views that his account was likely delusional and in recommending psychiatric assessment; there was no proven unlawful disclosure of medical records to the claimant's employer; disclosure to the claimant's GP was lawful and justified (see Health and Social Care Act 2012, s.251B); and there was no improper alteration of records requiring rectification.