In a response to a Prevention of Future Deaths report issued by HM Senior Coroner Mary Hassell following the death of Najib Ahmed Naagi, the Trust acknowledged that overnight observations had not been carried out at the times recorded in the medical notes.

During the inquest, CCTV footage showed that observations took place at 4.48am and 6.18am, despite records stating they had been completed at 4.30am, 5.30am and 6.30am. The clinical support worker involved only accepted the records were inaccurate after being challenged while giving evidence.

The coroner raised six concerns, including that the medical record was incorrect, the court had been misled and that inaccurate evidence could amount to contempt of court or perjury.

In its response, the Trust accepted that the records were wrong and confirmed it had referred the support worker to NHS Professionals (NHSP). Following an investigation, the worker has completed a reflective discussion and has been required to undergo further training, a competency assessment, a records-keeping exercise and a review of the NHSP Code of Behaviour. They have also received a formal standards and expectations warning.

The Trust said it had also identified shortcomings in its own observation recording system. At the time of the incident, staff used a pre-populated observation chart that did not allow them to record the exact time checks were carried out, making it difficult to document delayed observations accurately.

In response, the Trust has amended both its Supportive Observations Policy and observation forms to require staff to record the precise time each patient is checked. It has also introduced additional audits, competency reviews and governance measures to monitor compliance with observation standards.

The Trust said learning from the case has been shared across inpatient services and staff have been reminded of their professional responsibilities when preparing witness statements or giving evidence in legal proceedings.

Responding to the coroner's concerns, the Trust said it recognised the seriousness of the issues raised and acknowledged that honesty and accurate record-keeping are essential to maintaining public trust and ensuring safe patient care.