NHS trust ELFT may have faked records of up to 12 dead patients

A coroner has warned that staff at the East London NHS Foundation Trust (ELFT) appear to have not carried out required observations on patients, then simply written fake reports pretending they did.

Saba Naqshbandi KC, assistant coroner for Inner North London, raised the alarm after the trust admitted to “deliberate falsification of observation records” in one patient’s case.

Investigations commissioned by ELFT uncovered 11 subsequent “fatal incidents” where records may have been faked – and found cases of staff fabricating records were going up, not down.

Questioned by this newspaper, the trust – which serves Hackney, Newham, Tower Hamlets, the City of London, Bedfordshire and Luton – would not say this week that it was certain the fabrication of patient records had now stopped.

Mrs Naqshbandi has written a report stating: “I am concerned that action undertaken so 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.”

The scandal follows an inquest into the death of Mahamoud Hussain Ali, 40.

Mahamoud was found unresponsive in a room on Lea Ward, at the Tower Hamlets Centre for Mental Health, Mile End Hospital, on August 21, 2020.

He died five days later, at the Royal London Hospital in Whitechapel, having suffered brain death.

Mahamoud should have received checks every 15 minutes but a mental health nurse testified at his inquest in April that after discovering several checks never happened, she wrote fake observation reports, claiming in all of them that Mahamoud had been observed sleeping.

Since the falsification came to light, the coroner wrote: “Evidence has been provided by the trust that since Mr Ali’s death… there have been 11 fatal incidents where observation records may have been filled in where observations have not been conducted.”

But the trust did not tell the coroner the dates or locations of these 11 other deaths, nor the circumstances in which the affected patients died.

It also did not disclose the results of any subsequent investigations or whether any “consequential action” followed.

All that is known is that one of the deaths, in May 2023, occurred on the same ward Mr Ali had been on – Lea Ward at Mile End Hospital.

ELFT told the coroner that concerns had been raised in September 2022 about “the quality and consistency of engagement and observation practice”.

Then, in October 2023, it wrote to staff about “falsification of observation records”.

But the trust added: “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.”

It also told the coroner that while “the majority” of the 11 further fatal incidents “pre-date” its work to tackle fabrication of records, some have happened subsequently.

Mahamoud was taken to Homerton University Hospital by ambulance twice in one day (August 19, 2020), both after suffering falls in public.

A psychiatrist assessed his mental health on August 20 and he was sectioned, leading to his placement at Mile End Hospital.

He was placed in isolation pending the results of a Covid test. Staff were ordered to check on him every 15 minutes, but failed to do so.

When he was found unresponsive on August 21, he was taken to the Royal London, where a CT scan identified “unsurvivable early brain death”.

An inquest jury ruled his death an accident.

An ELFT spokesperson 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 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.”