Mohammed Akramuzzaman
4 Jun 2024 · Coroner Mary Hassell · Inner North London
The coroner's concerns
1. lack of medical assessment and intervention
“BTP officers attended Mr [name redacted] very quickly after a concern was raised by a member of the public, and they asked him if he was alright and if he wanted medical treatment”
2. failure to obtain verbal consent or assess condition
“They never actually heard him speak”
3. inadequate physical assessment
“They did not attempt to stand him up to see if he was able to support himself.”
4. misjudgment of medical cause
“it was impossible to decide so quickly that this was a drug comedown”
5. lack of follow‑up monitoring
“nobody went back to check on Mr [name redacted] later”
6. absence of organisational learning
“they struck me as defensive, and they were unable to point to any specific learning or any changes in their procedures”