Mohamed Atef Hakmi v East & North Hertfordshire NHS Trust & Anor

In a clinical negligence claim arising from the withholding of thrombolysis, the court distinguished between a patient’s subjective symptoms and objective clinical signs. The defendants’ documentation fell below the required standard, and the remote consultant should have disclosed the failed video link and sought an alternative consultant review. However, the claimant failed to prove that earlier thrombolysis would probably have produced a better outcome. Evidence that a treatment might have improved the chance of recovery was insufficient to establish causation on the balance of probabilities. A claim under section 57 of the Criminal Justice and Courts Act 2015 also failed because fundamental dishonesty was not proved. The claim was dismissed, with a costs order reflecting the unsuccessful dishonesty allegation.

The claimant, a consultant orthopaedic surgeon, suffered a second stroke after attending hospital with fluctuating right-sided symptoms. He alleged that the defendant hospitals had acted negligently by failing to take and communicate an adequate history and neurological examination, by relying on a defective telemedicine consultation, and by refusing thrombolysis.

The court assessed the conflicting oral evidence, contemporaneous records and expert evidence on breach and causation. It also considered an allegation that the claimant had deliberately exaggerated his physical or cognitive impairment and was therefore fundamentally dishonest under section 57 of the Criminal Justice and Courts Act 2015. The central issues were whether there had been a breach of duty, whether thrombolysis would probably have improved the outcome, and whether the dishonesty defence was established.

1. Evidence and breach. The court accepted that the claimant and his wife had experienced a highly personal and distressing event, but remained alert to the possibility that recollections had become reconstructed over time. The emergency documentation was below the required standard because it did not record the history adequately. However, the neurological examinations by the emergency registrar and stroke nurse were not proved to be inadequate, and the recorded NIHSS findings did not establish a score sufficient to require thrombolysis.
2. Telemedicine. The stroke consultant’s computer malfunctioned, preventing video observation and access to the imaging. He should have checked the equipment before starting his shift, informed the claimant that the consultation was suboptimal, and contacted another consultant. The court considered it unlikely that an alternative assessment would have resulted in thrombolysis, given the subtle objective signs and the likely NIHSS score.
3. Causation. The relevant treatment window was 4½ hours. The court accepted that the probable cause of the second stroke was a clot, but found the evidence concerning thrombolysis for lacunar stroke insufficient to establish that treatment would probably have altered the outcome. The DRAGON score predicted the outcome of treated patients but did not compare treated and untreated cohorts. At most, the claimant had lost a chance of a better recovery, which did not prove causation for the pleaded claim.
4. Fundamental dishonesty. Applying the requirements identified in Cojanu v Essex Partnership University NHS Trust [2022] 4 WLR 33, the defendants had to prove dishonesty on the balance of probabilities and show that it was fundamental to the primary or related claim. The court preferred Dr Ford’s evidence and found that the claimant’s test performance could be explained by organic impairment, psychological condition and testing circumstances. Dishonesty was not proved.
5. Disposition and costs. The claim was dismissed. The claimant was ordered to pay the defendants’ costs of the action, not to be enforced without leave. The defendants were ordered to pay 15% of the claimant’s costs incurred from 18 March 2025, reflecting their failure to establish fundamental dishonesty.