“that do not appear to have been addressed adequately, or at all, and the evidence also…”

The coroner’s concerns

that do not appear to have been addressed adequately, or at all, and the evidence also revealed other matters that have not been identified in the Trust’s improvement plan. The MATTERS OF CONCERN are as follows: 1) Patient Observations (generally) I am aware that, prior to final admission under the care of the Trust in 2022, other concerns had been raised by a coroner regarding patient observations within the Trust. Those concerns were first raised in 2021 (following a patient death in 2018). Concerns included the quality of observations and the falsification of observations. Despite assurances from the Trust in numerous action plans since, the evidence in this inquest revealed widespread concerns across two wards at THCMH (Brick Lane Ward and Rosebank Ward) about observations that were carried out. Such concerns included: the level of detail in observation records not meeting the expectations of the Trust’s own policy; the accuracy of timing’s in some observations was questionable; observations were often not used as a tool to aid therapeutic engagement with patients; and some observations were inaccurate or possibly falsified. The evidence received and heard during the inquest did not reassure me that this matter has been adequately addressed. Given the importance of observations in keeping patients safe, I remain concerned that significant risks remain. 2) 1:1 or ‘within eyesight’ Observations The CCTV footage played at inquest showed a member of staff who was allocated to ‘within eyesight’ observations of another patient sat on the back of a chair (with their back facing the patient’s bedroom door) and engaged on their mobile telephone. That member of staff initially told the court that they were conducting the ‘within eyesight’ observations correctly and could see the patient in question. This raises significant concern, not only about the quality of 1:1 observation but also about staff attitudes and approach to observations that are integral to keeping patients safe (see below at para 7)). 3) Auditing of record keeping The Trust’s evidence regarding auditing nursing / clinical records provided little, if any, reassurance that the system in place is bringing about a truly measurable or meaningful change. 4) The door-locking / ‘fob’ system This was not working at the time of death and the jury found this to have been a contributory factor in her death, in that it allowed her access to other patient’s bedrooms. There was evidence to suggest that the system is now working as intended, which is positive. However, the cause for concern is whether there is a sufficient system in place to guide and assist staff in what to do if the door locking system were to fail again. The evidence was that, at the material time, staff were aware that this was an issue that put patients at increased risk; however, there was evidence that staff did not fully appreciate the nature and extent of the increased risk or deploy measures to sufficiently reduce the risk. 5) Risk assessment of patients The Trust accepted that there were issues in the risk assessment of in that: what documentation there was stated there were risks but did not fully assess the risks; there was no ‘My Safety Plan’ in place; and ‘Dialog+’ had not completed. At the time, staff said that they had been trained regarding risk assessment and its importance. However, when giving evidence at the inquest, numerous members of staff were vague in their understanding of risk assessment. For example, a senior member of staff said that it was possible to complete the ‘My Safety Plan’ documentation even if a patient did not want to engage with the process, whereas other members of staff were insistent that if a patient doesn’t engage then the document should not be completed. 6) Understanding of risk Some Trust witnesses who gave evidence appeared to lack an appreciable understanding of what could constitute serious risks to patients. In some instances, this seemed to go beyond possible training issues and raised potential questions about suitability for being in a caring role. 7) Attitudinal concerns There was a recurrent theme in the evidence provided by nursing and support staff that certain clinical tasks (including, but not limited to, the completion of risk assessment documentation) could simply be left for the next shift to complete. The net result of this was that such tasks were not completed, allowing the risks associated with non-completion to be perpetuated. The court was told that all shifts (on Rosebank Ward in particular) were busy and staff often did not have time to complete the tasks allocated to them. However, CCTV footage showed, for example, a member of staff (allocated to complete observations and not on a designated break at the material times) checking their mobile telephone and sitting in the lounge reading the newspaper instead of undertaking their clinical role. 8) Effective clinical oversight at THCMH There was clear evidence at the inquest that, following an extended bank holiday weekend period, there was a lack of consultant cover on Rosebank Ward and the male PICU ward, which led to one consultant attempting to cover both wards. This, in itself, is not the concern for the purposes of this report, but it puts the matter into some context. The consultant that was providing the cover to both wards gave evidence at the inquest, as did other senior nursing staff. The consultant’s own evidence raised questions about their own professional judgment in providing that cover to the wards and assessing the risks. The evidence of a senior nurse was that specific concerns had previously been raised about the consultant in question, including that consultant not being a “very responsive consultant” and there having been “a pattern” with this consultant not reviewing patients in a timely manner. The court was told that those concerns had previously been raised with the Trust’s Clinical Director and Associate Clinical Director and

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0507

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0