Luke Raggatt, 40, died at Royal Cornwall Hospital after suffering a seizure during a cigarette break
Missed opportunities in Luke Raggatt’s care were found to have contributed to the seizure that led to his death (Image: Supplied)
A musician who suffered a traumatic brain injury after an alcohol withdrawal-induced seizure died after “missed opportunities” and “neglect” in his medical care, an inquest has heard.
Luke Raggatt, from Redruth, Cornwall, was 40 years old when he died at Royal Cornwall Hospital, Truro, on October 26, 2024.
An inquest into his death which concluded on Thursday (December 11, 2025) heard he had been admitted to Treliske’s emergency department on October 23 with a swollen arm.
His medical history showed he drank six to seven pints of cider each evening to help him sleep and had suffered a previous seizure in 2021. The inquest heard this history was available to medical staff when he was admitted but was not considered.
The department’s matron said during the inquest that Luke was triaged for his arm within the necessary 15-minute period and the appropriate observations took place.
Luke Raggatt died in October last year during his hospital stay (Image: CornwallLive)
She also noted that patients are asked questions pertinent to their complaint at the triage stage and that asking if a patient was alcohol dependent would not necessarily be requested during triage unless the patient offered that information.
The inquest heard Luke went on to wait over 30 hours in the ward due to “extreme overcrowding” and on October 24, he went for a cigarette break outside the hospital with plans to leave.
It was at this time that he suffered a seizure, falling and hitting his head outside the hospital. This was witnessed by paramedics outside the hospital and Luke was taken to the resuscitation room.
His partner, Patricia Burnett, said in evidence that after the seizure, Luke had a large lump on the back of his head, presented as very disorientated and didn’t know what had happened.
When she asked medics to take a scan of her partner’s head, however, she was told it was not applicable at the time.
Instead, Luke stayed overnight for observation, before waking in the morning and appearing somewhat better.
The inquest heard he then had a “rapid deterioration,” clutching his head and becoming unresponsive.
He was seen by an ED doctor and consultant and it was at this point they became aware Luke had been withdrawn from alcohol for over 24 hours.
Luke was sent to have a CT scan which showed he had a life-ending brain injury that could not be treated.
Pathologist Dr Tom Grigor said Luke’s cause of death was a brain haemorrhage following a seizure from alcohol withdrawal.
Assistant Coroner for Cornwall and the Isle of Scilly Emma Hillson, accepted this cause of death, noting Luke was medically reviewed twice prior to his seizure and despite prompting in clerking notes, his alcohol withdrawal was not considered.
She also said there were “missed opportunities to render basic medical care” in the form of alcohol withdrawal medication that were “especially important” in the context of an overcrowded hospital.
Ms Hillson noted that on the balance of probability, this lack of treatment “more likely than not” led to Luke suffering a seizure, which led to his traumatic brain injury.
She added that there had also been “missed opportunities” on medical review with opportunities for members of staff to view Luke’s medical history, which would have shown his history of alcohol dependence and a previous seizure that would warrant a CT scan sooner.
Ms Hillson found that Luke should have met the criteria for a CT head scan, considering it would have been more than likely known he had hit his head during his seizure.
She also noted that if his previous seizure had been noted appropriately, it is her view this would have indicated a head scan was necessary.
The coroner did note, however, that she cannot say whether the fact a CT scan was not taken at this time more than minimally contributed to Luke’s death.
But, she said: “There had been missed opportunities upon medical review to recognise his alcohol consumption and previous seizure and therefore provide seizure preventative medication. On the evidence it is more likely than not that this seizure was preventable and this omission in his care more than minimally contributed to his death due to the resultant fatal head injury.”
Ms Hillson recorded a conclusion of traumatic head injury following an alcohol withdrawal seizure, contributed to by neglect.
A spokesperson for the Royal Cornwall Hospitals said: “We are deeply saddened by the tragic death of Luke in October 2024. Our heartfelt thoughts and condolences remain with his family and friends at this incredibly difficult time.
“We fully accept the Coroner’s findings and the concerns raised during the inquest. We are committed to acting on these and ensuring that learning is embedded across our services.
“Working closely with our NHS partners and wider stakeholders, we have already taken steps to reduce crowding in our Emergency Department and to improve patient flow throughout the hospital. This remains a top priority.
“Looking ahead, the introduction of ‘e-Care’, our new electronic patient record, in 2026 will give clinicians instant access to essential patient information in one secure, central system, supporting safer and more joined-up care.
“Once again, we extend our deepest sympathies to Luke’s loved ones.”
Ms Hillson accepted that measures are being taken to introduce the new record-keeping system for 2026 in addition to measures being actively taken to reduce overcrowding.
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