A coroner has raised concerns staff at an east London hospitals trust have been routinely falsifying records after failing to check on patients - including 12 cases where patients died.
Mahamoud Ali, 40, died after staff repeatedly failed to carry out 15-minute observations on him as he was in Covid isolation at Tower Hamlets Centre for Mental Health, at Mile End Hospital in August 2020.
Following his death, coroner Saba Naqshbandi KC has sounded the alarm about an ongoing culture of “deliberate falsification of observation records” at East London NHS Foundation Trust, which runs the facility.
She said that since Mr Ali’s death, another 11 patients across the Trust’s hospitals have died in situations where staff are thought to have falsely filled out observations, when patients have not been checked on.
Despite efforts to clamp down on the issue, the Trust has reportedly seen an increase in records being “falsified to reflect [observations] had been done”.
Mr Ali was first taken to hospital by ambulance on August 19, 2020, after he fell over in the street. A CT scan showed no signs of a skull fracture or bleeding and he discharged himself.
But after falling over again later the same morning he was taken back to the same hospital by ambulance, where another scan showed no change.
Concerned about his behaviour and mental health, medics ordered a psychiatric assessment and Mr Ali was detained under Mental Health Act and transferred to Lea Ward, Mile End Mental Health Hospital.
He arrived there just before 7pm on August 20, 2020. He was placed in isolation, pending a Covid-19 test, and staff were ordered to carry out observations on him every quarter-of-an-hour.
At 6pm the following day, he was found unresponsive on the floor of his room.
He was taken to Royal London Hospital where a CT scan showed he had suffered “unsurvivable early brain death” and surgery was ruled “futile”.
He died five days later, on August 26. A post-mortem later found he died as a result of bronchopneumonia, caused by ischaemic encephalopathy (brain injury caused by a decrease in oxygen or blood flow) and subdural haematoma (a bleed on the brain, usually caused by a head injury).During Mr Ali’s inquest, it emerged that staff at Mile End Hospital’s mental health ward had failed to carry out checks on him.
A registered mental health nurse said that around 5.40pm on August 21 she saw observations had not been completed since 4.45pm.
She gave evidence that she then completed his chart “as if she had conducted those observations, recording that Mr Ali was asleep”.
It is not clear how long Mr Ali was unresponsive before he was found by staff, around 6pm.
East London NHS Foundation Trust “has acknowledged that the deliberate falsification of observation records is not acceptable”, said the coroner, in a ‘prevention of future deaths’ report published after Mr Ali’s inquest.
But concerning evidence provided by the Trust shows that since Mr Ali’s death, there have been 11 deaths of patients whose observation records “may have been filled in when observations have not been conducted”.
One of these deaths, in May 2023, took place in Lea Ward - the men’s acute mental health ward where Mr Ali had been detained.
The coroner said the Trust has not provided her with the specific circumstances of the deaths, or of any investigations or actions undertaken to address each incident.
Ten months ago (October 2023), the Trust wrote to staff about ‘falsification of observation records’.
It highlighted concerns coroners had raised “about the quality and consistency of engagement and observation practice”, and detailed work the Trust had been doing since September 2022 to improve practice around observations.
But the Trust said in the letter: “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done.”
In her report to the Trust, Ms Naqshbandi wrote: “I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur.”
East London NHS Foundation Trust runs 11 hospitals as well as dozens of clinics, including Newham General Hospital, Richmond Royal Hospital, East Ham Care Centre, Newham Centre for Mental Health, and The Coborn Centre for Adolescent Mental Health.
A spokesperson for the East London NHS Foundation Trust said: “The Trust would like to express its deepest sympathies to Mahamoud Ali's friends and family. We acknowledge that in the care provided, our standards fell short and for that we are very sorry.
“We are reviewing the comments made by the coroner after writing to us. We remain strongly committed to learning from the shortcomings, and addressing them, to improve the quality and safety of care our service users receive.”
