Medical Negligence Lawyers Join Loved Ones In Calling For Lessons To Be Learned

A renowned musician suffering a psychotic episode died after falling out of his bedroom window following “several missed opportunities” and “shortcomings” in his care, an investigation has found.

Paramedics had been called to Ebow Graham’s flat in Clapton, East London, the afternoon before he died. Friends had dialled 999 after becoming concerned he was displaying “out of character” behaviour. 

However, paramedics wrongly left without seeking the opinion of mental health specialists and assuming Ebow had capacity to decline treatment.

His friends then later called a mental health crisis line. The call handler “underestimated” Ebow’s condition and “potential risk” and said they would arrange for him to be assessed the following morning, an investigation report said. 

Still concerned about his condition, friends took Ebow, a founding member of hip-hop electronic crossover group Foreign Beggars, to hospital. Ebow, who was agitated, left before he was assessed due to prolonged waiting times. 

He fell from a third-floor window shortly after returning home and his friends called 999. Professionally known as ‘Metropolis’, Ebow died aged 40, shortly after arriving at hospital. 

Ebow's loved ones ask medical negligence lawyers to investigate

Following his death, Ebow’s former partner Francesca Macri, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate his care and secure answers. 

Francesca has now joined her legal team in calling for lessons to be learned. 

It comes after Irwin Mitchell secured an undisclosed settlement from London Ambulance Service and East London NHS Foundation Trust – which ran the crisis line. Both admitted that they had breached their duty of care to Ebow.

Leena Savjani is the expert medical negligence lawyer at Irwin Mitchell representing Francesca.

Expert Opinion

“The past few years and trying to come to terms with Ebow’s death and the traumatic events surrounding it have been incredibly difficult for his loved ones.

“Understandably they’ve had a number of concerns about what happened. While nothing can make up for Ebow’s death we’re pleased that we’ve been able to provide them with the answers they deserve.

“However, it’s now vital that lessons are learned from the issues that have been identified to help improve patient safety in relation to mental health.

“We’d always urge health professionals to listen carefully to loved ones when a person is in distress as it can help ensure that urgent assessments are carried out and appropriate help can be provided to those who need it.” Leena Savjani

Medical negligence: Ebow Graham's story

Ebow had no known history of mental illness. At about 4.20pm on 17 April, 2020, friends called 999 concerned about his unusually erratic behaviour that had started earlier that day. However, paramedics left as they deemed him to have capacity over his care, a serious incident investigation report by London Ambulance Service later found.

At around 6.30pm a family friend, who was a GP, and Ebow’s flatmate called the mental health crisis line run by East London NHS Foundation Trust as they remained concerned about Ebow’s state of mind. They said he was acting out of character and had been using more cannabis than usual. 

However, instead of organising an urgent same-day assessment  the mental health crisis line nurse they spoke to said they would arrange for Ebow to be contacted the following morning.  Due to the level of distress Ebow appeared to be in, his friends decided to take him to the local hospital as they did not want to wait until the following morning. However, Ebow was agitated and restless and was unable to stay in the hospital waiting area to be triaged – he left before he was seen by anyone. 

At around 11.20pm and 11.55pm London Ambulance Service received further emergency calls from Ebow’s friend who remained gravely concerned about his condition. 

At around 12.25am on 18 April, 2020, police informed the ambulance service that Ebow had fallen out of a window. 

He had suffered multiple injuries. Ebow suffered a cardiac arrest on the way to hospital. He died shortly after arriving at hospital.

London Ambulance Service and Hospital Trust admit breaches of duty

Following legal submissions by Irwin Mitchell, London Ambulance Service admitted breach of duty. It admitted that when paramedics were at Ebow’s flat on the afternoon of 17 April, 2020, they failed to follow appropriate protocols and contact the mental health team for advice.

East London NHS Foundation Trust also admitted that when Ebow’s friends called the crisis line it failed to arrange for Ebow to undergo an urgent at home mental health assessment, which should have occurred within four hours. 

A serious investigation report by London Ambulance Service also concluded there were “several missed opportunities” to get Ebow access to “expert help” in terms of a mental health referral and advanced clinical care following his fall.

A patient safety review report by East London NHS Foundation Trust, also found “shortcomings” in how the call to the crisis line was handled. This included that the call handler “underestimated the extent and immediacy of his potential risk.”

Loved ones call for improved care

Francesca said: “As well as a popular musician, Ebow was a fantastic, loving and caring person. All his friends and family have been left devastated by his death.

“Ebow touched so many lives. It might be more than four years since he died, but  it remains difficult to come to terms with the fact he’s no longer with us. 

“Since Ebow’s death we’ve had a number of concerns about the treatment he received, or rather didn’t receive, on that day. 

“His behaviour was so out of character that we  knew he was mentally unwell and needed urgent specialist treatment. The paramedics that attended on that day were dismissive and flippant and ignored what Ebow’s friends were telling them. They asked whether Ebow had smoked cannabis and this concerns me – were they asking this because Ebow was a Black man with dreadlocks? Why did it even matter what had caused Ebow’s psychosis and shouldn’t the focus have been on helping him? 

"I cannot help but wonder whether racial profiling played any part in the way Ebow was treated.  We’ll never know, but there are studies and surveys that have reported that black people in the UK have experienced prejudice from health workers because of their ethnicity. 

“Whatever Ebow did he still should have received the help and care he deserved. 

“Our only hope now is that the heartbreak we’ve suffered highlights the dangers of drugs but also the need for those with mental health issues to receive the most appropriate and swift treatment. If Ebow had received the correct care on that fateful day he may still be here with us today. 

“My only wish now is that his death was not in vain but can be used to raise awareness of acute mental health issues and the importance of providing urgent support and intervention when needed.”

Find out more about Irwin Mitchell's expertise in supporting families affected by care issues at our dedicated medical negligence section. Alternatively, to speak to an expert contact us or call 0370 1500 100.