Failures to recognise alcohol dependence, manage withdrawal safely or identify thiamine deficiency can result in serious and potentially permanent harm. In a recent INNEG webinar, Advanced Clinical Practitioner and Independent Expert Witness Hazel Peet explored these risks, examining how clinical decisions, treatment delays and missed opportunities for escalation can become central to clinical negligence claims.

[Watch the full webinar with Hazel Peet here >]

Alcohol Use Disorder: Understanding Clinical Risk

Alcohol use disorder describes a medical condition in which an individual experiences difficulty controlling their alcohol consumption despite adverse consequences.

However, not everyone who drinks excessively is physically dependent on alcohol, and not every patient with alcohol-related harm will experience withdrawal.

This distinction is particularly important in clinical negligence investigations because treatment should be based on the patient's individual presentation, history and clinical risk rather than assumptions about their drinking habits.

Hazel explained that alcohol-related presentations can fall into different categories, including hazardous drinking, harmful drinking and alcohol dependence.

Dependence involves changes in the regulation of alcohol use, which may include impaired control, increasing priority given to drinking and physiological adaptations such as tolerance and withdrawal.

In clinical practice, recognising these differences helps establish whether a patient is at risk of acute withdrawal, nutritional deficiency or other complications during hospital admission.

Why Alcohol Histories Matter

A recurring concern highlighted during the webinar was the use of vague descriptions in medical records.

Terms such as 'ETOH excess', 'heavy drinker' or 'social drinker' may indicate alcohol consumption but provide limited information about the patient's actual dependence or withdrawal risk.

A meaningful clinical assessment should establish:

• The type, quantity, frequency and pattern of alcohol consumption.
• When the patient last consumed alcohol.
• Previous withdrawal symptoms, seizures or delirium.
• Evidence of tolerance, dependence or relief drinking.
• Nutritional status, other illnesses and relevant medication.

Screening tools such as the Alcohol Use Disorders Identification Test (AUDIT) and Severity of Alcohol Dependence Questionnaire (SADQ) can support this assessment.

However, Hazel emphasised that screening scores should inform clinical judgement rather than replace it.

For solicitors reviewing medical records, the central question is whether sufficient information was gathered to identify foreseeable clinical risks and develop an appropriate treatment plan.

Alcohol Withdrawal: Clinical Risks and Mismanagement

Alcohol withdrawal occurs when an individual who has developed physical dependence substantially reduces or stops alcohol consumption.

Prolonged alcohol exposure changes how the nervous system regulates inhibitory and excitatory activity. When alcohol levels fall, these adaptations can leave the nervous system overactive, producing withdrawal symptoms.

These may include anxiety, sweating, tremors, agitation and nausea. More severe withdrawal can involve seizures or delirium tremens, a potentially life-threatening emergency.

Importantly, withdrawal symptoms can begin while alcohol remains in the bloodstream.

A positive alcohol reading therefore does not automatically exclude withdrawal or make withdrawal medication inappropriate.

Safe Withdrawal Management

Benzodiazepines, including chlordiazepoxide, are commonly used to control alcohol withdrawal symptoms.

However, treatment must balance two competing risks: inadequate medication, which may allow withdrawal to progress, and excessive sedation, particularly when alcohol or other sedating substances remain present.

Hazel explained that clinicians should continually assess the patient's condition, including consciousness, respiratory status, agitation and response to medication.

Withdrawal assessment tools, including CIWA-Ar and the Glasgow Modified Alcohol Withdrawal Scale, can assist clinical teams, but they cannot replace wider clinical judgement.

Where symptoms persist or a patient becomes increasingly drowsy, confused or unsteady, further assessment may be necessary.

When Withdrawal Management Becomes a Medico-Legal Concern

Potential failures include delayed or omitted medication, inappropriate dosing, inadequate monitoring and a failure to reconsider the diagnosis when the patient's condition changes.

A further concern is ineffective communication between departments.

Patients transferred from emergency departments to hospital wards require clear documentation of treatment already administered, outstanding clinical risks and the monitoring or escalation arrangements required.

Key insight: A withdrawal score or medication prescription alone does not demonstrate safe management. The records must also show how the clinical team monitored the patient's response and acted on deterioration.

For solicitors, comparing prescription charts with medication administration records and clinical observations can help establish whether a treatment plan was implemented, reviewed and adjusted appropriately.

Wernicke's Encephalopathy: Clinical Risks

Wernicke's encephalopathy is an acute neurological emergency caused by thiamine, or vitamin B1, deficiency.

It can develop in patients with prolonged harmful alcohol use because alcohol may impair thiamine absorption, poor nutrition can reduce intake and liver disease may affect thiamine stores.

The increased metabolic demands associated with acute illness and alcohol withdrawal can further increase the risk.

Without timely recognition and treatment, Wernicke's encephalopathy can result in permanent neurological injury.

Recognising the Warning Signs

Wernicke's encephalopathy is traditionally associated with three clinical features:

• Altered mental state: Confusion, memory difficulties or changes in behaviour.
• Ataxia: Impaired coordination, instability or difficulty walking.
• Eye movement abnormalities: Including nystagmus or ophthalmoplegia.

However, the full combination of symptoms is frequently absent.

A patient may initially appear mildly confused, forgetful or unsteady, with no obvious eye movement abnormalities.

These symptoms can also be attributed to intoxication, withdrawal, infection or other medical conditions.

This creates a significant diagnostic challenge.

Clinicians must consider whether an existing diagnosis adequately explains the presentation or whether additional conditions, including Wernicke's encephalopathy, require investigation and treatment.

Waiting for all three classical features to develop may delay potentially protective treatment.

Thiamine Treatment: Prevention Versus Treatment

An important distinction in clinical negligence investigations is the difference between thiamine prophylaxis and therapeutic treatment.

Prophylaxis aims to prevent deficiency-related neurological injury in patients considered at risk.

Therapeutic treatment is required when Wernicke's encephalopathy is suspected or established.

Hazel highlighted that suspected Wernicke's encephalopathy requires urgent parenteral thiamine treatment under an appropriate clinical protocol.

Oral thiamine should not be regarded as an adequate substitute for urgent therapeutic treatment of suspected Wernicke's in an acute hospital setting.

When reviewing clinical records, solicitors should therefore establish not only whether thiamine was prescribed, but also the route, dose, frequency, timing and clinical indication.

The applicable guidance and accepted standards must be considered in the context of when the treatment took place.

Medico-Legal Considerations

Alcohol-related negligence claims can involve several overlapping clinical issues.

A patient may experience withdrawal while simultaneously being affected by thiamine deficiency, infection, medication effects or an unrelated neurological condition.

This makes careful examination of the contemporaneous medical evidence particularly important.

Establishing Breach of Duty

A potential breach may arise where clinicians fail to obtain an appropriate alcohol history, recognise significant warning signs, administer indicated treatment or respond adequately to deterioration.

However, an adverse outcome does not automatically establish negligent care.

The relevant question is whether the assessment and treatment provided were reasonable in light of the information available at that particular time.

A retrospective review must therefore distinguish between symptoms that were recognisable during admission and information that only became apparent later.

Establishing Causation

Causation requires consideration of whether an identified failure materially affected the patient's outcome under the applicable legal test.

In cases involving suspected Wernicke's encephalopathy, the timing of recognition and thiamine administration may be particularly significant.

Earlier treatment may prevent lasting neurological harm, but the likely outcome with appropriate care must be assessed individually.

Factors such as the patient's condition at presentation, duration of symptoms, nutritional status and neurological deterioration may all be relevant.

Similarly, where a patient experiences a fall, seizure or intracranial haemorrhage during withdrawal management, these events should not automatically be attributed to alcohol withdrawal.

Alternative explanations and the sequence of events require careful clinical investigation.

A detailed chronology, supported by appropriate expert evidence, can help clarify both alleged breaches and the relationship between treatment decisions and subsequent injury.

Case Examples and Outcomes

During the webinar, Hazel examined two clinical cases illustrating how alcohol-related risks can be missed or inadequately managed.

Case Study 1: Repeated Falls and Neurological Deterioration

The first case concerned a man who presented to an emergency department intoxicated, having reportedly consumed excessive alcohol, eaten poorly and become unable to walk.

Despite these concerns, the clinical history did not adequately document previous withdrawal severity.

A withdrawal assessment was undertaken and chlordiazepoxide administered while the patient remained clinically intoxicated.

This did not necessarily make treatment inappropriate, but it created a need to establish the reliability of the assessment, medication requirements and subsequent monitoring.

Following transfer to the ward, the patient experienced an unwitnessed fall.

He became increasingly confused and experienced further falls, despite being instructed not to leave his bed without assistance.

The records did not document neurological observations or an appropriate post-fall review.

His deterioration continued, followed by a seizure and catastrophic haemorrhage.

Key Medico-Legal Considerations

The case illustrates several important areas for investigation.

First, the patient's inability to walk and poor nutritional status required consideration beyond a diagnosis of intoxication.

Second, repeated falls should have prompted reassessment of the existing care plan, including whether the patient could understand and follow verbal instructions.

Third, increasing confusion and drowsiness required consideration of medication effects, withdrawal, thiamine deficiency, neurological injury and other potential causes.

The existence of a deprivation of liberty authorisation did not itself provide adequate supervision or prevent further falls.

For solicitors, the case highlights the importance of examining whether falls prevention, neurological monitoring and escalation arrangements were appropriate as the patient's condition deteriorated.

The precise relationship between the falls, seizure and haemorrhage would require separate expert consideration rather than being assumed from their sequence.

Case Study 2: Missed Wernicke's and Permanent Neurological Injury

The second case involved a woman who attended an emergency department with symptoms of gastritis and mild confusion.

Possible sepsis was considered, and she was treated before being discharged with oral antibiotics.

However, no alcohol history had been obtained.

Following discharge, her confusion worsened and she required readmission.

During the subsequent admission, nystagmus prompted an ophthalmology review. A history obtained from her husband then identified relevant alcohol-related risks.

Intravenous thiamine was eventually administered, but the patient sustained permanent neurological injury and developed Korsakoff syndrome.

She subsequently required 24-hour care.

Missed Opportunities for Earlier Intervention

Several potential points of intervention were identified.

At the initial presentation, the presence of confusion should have prompted consideration of its underlying cause, alongside an assessment of nutritional status and alcohol consumption.

Before discharge, clinicians needed to establish whether the confusion had resolved and whether the working diagnosis adequately explained the patient's symptoms.

On readmission, worsening confusion warranted reconsideration of the differential diagnosis.

Obtaining collateral information from her husband earlier may also have assisted clinicians in identifying alcohol-related risk.

The case demonstrates how delays in recognition and treatment may have significant implications for long-term cognitive function and care needs.

However, establishing whether earlier intervention would have prevented or reduced the injury requires an individual causation assessment.

Long-Term Harm and Quantum

One of the most significant potential consequences of untreated Wernicke's encephalopathy is Korsakoff syndrome.

This condition can cause profound memory impairment, particularly difficulty forming new memories.

Individuals may appear able to communicate normally during a brief interaction while struggling to retain essential information afterwards.

The resulting disability can affect medication management, personal safety, nutrition, independent living and everyday decision-making.

In severe cases, continuous supervision or 24-hour care may be necessary.

For solicitors investigating neurological injury claims, these consequences may be relevant to the assessment of future care, rehabilitation, accommodation, support needs and loss of independence.

The extent of any disability and its relationship to the alleged negligence must be established through appropriate evidence.

Key Takeaways for Solicitors

The webinar highlights the importance of examining not simply what diagnosis was recorded, but how the patient's changing presentation influenced assessment and treatment.

When investigating potential alcohol-related clinical negligence, solicitors should consider the following:

1. Was an adequate alcohol and nutritional history obtained?

General descriptions of alcohol consumption may be insufficient to identify dependence, withdrawal risk or thiamine deficiency.

2. Were significant symptoms properly investigated?

Confusion, unsteadiness, repeated falls and abnormal eye movements may indicate conditions beyond intoxication or withdrawal.

3. Was treatment appropriate and timely?

Medication records should be reviewed alongside the patient's clinical condition, monitoring requirements and response to treatment.

4. Did the clinical team respond to deterioration?

Repeated falls, increasing drowsiness, persistent withdrawal symptoms or worsening confusion may indicate a need for reassessment and escalation.

5. Were opportunities for earlier intervention missed?

A structured chronology can help identify when relevant risks became recognisable and whether action was taken within an appropriate timeframe.

6. What difference would appropriate treatment have made?

Breach of duty and causation require separate consideration. Earlier treatment may improve outcomes, but the likely effect must be assessed with reference to the individual patient's circumstances.

Expert Evidence in Alcohol-Related Clinical Negligence Claims

Cases involving alcohol withdrawal, Wernicke's encephalopathy and neurological deterioration often require expertise across different areas of clinical practice.

Depending on the circumstances, this may involve assessment of emergency care, advanced clinical practice, nursing management, prescribing, neurological diagnosis and long-term prognosis.

Hazel also highlighted the potential role of appropriately experienced Advanced Clinical Practitioners in providing medico-legal opinions.

The suitability of an expert should be assessed by reference to their actual training, clinical responsibilities and relevant experience rather than their professional title alone.

Different experts may be required to address distinct aspects of the clinical pathway, including breach of duty, causation and prognosis.

Watch the Full Webinar

Alcohol-related clinical negligence claims often turn on the quality of the initial assessment, the timeliness of treatment and whether clinical teams recognised and responded to deterioration.

In this webinar, Hazel Peet shares practical clinical insight into the management of alcohol withdrawal and Wernicke's encephalopathy, supported by case examples that demonstrate the potential consequences of missed opportunities for intervention.

[Watch the full webinar with Hazel Peet here >]

For support identifying appropriately qualified experts in complex clinical negligence claims, contact the INNEG team at info@inneg.co.uk.