“The clinical support worker who had been tasked with conducting Mr Naagi’s observations…”

The coroner’s concerns

The clinical support worker who had been tasked with conducting Mr Naagi’s observations recorded that she had observed Mr Naagi at the following times: 4.30am 5.30am 6.30am She reiterated that in her statement and in her oral evidence at inquest. She did not volunteer the fact that her record was wrong. It was only when I put it to her in quite robust terms that she accepted this. In fact, the ward CCTV showed that she looked through the observation panel at the following times: 4.48am 6.18am Thus, the record she made did not reflect the actions she took. The consequences of this are as follows: 1. A patient’s medical record was wrong. Any healthcare professional seeking to understand when Mr Naagi had been observed to be well by reading the record would have been given the wrong information. 2. The fact that this record was wrong casts doubt on the remainder of the record, both in terms of this individual (was he actually well at the times recorded?) and the other patients (were they observed when the record indicates that they were observed?). 3. The court was misled. 3 Observations should be conducted when they are meant to be conducted, but if they are not then this fact must be recorded contemporaneously. It was put to me by the trust’s solicitor that because the clinical support worker later looked through the observation panel at 6.36am, this meant that the number of observations recorded was accurate and so the later observation somehow made good the lack of earlier observation and corrected the wrong recording. That is simply not the case. Proper patient care demands that patient records are accurate and not in any way fabricated. Regarding the giving of inaccurate evidence in court, this may amount to a contempt of court, it may amount to perjury, it may be punishable by a fine or even by a term of imprisonment. For your patients, it obstructs learning from deaths. 10 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every interested person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I have sent the report to: The daughter of Najib Naagi I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 5 above for additional information relating to the publication of reports and responses. SIGNATURE ME Hassell 4

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, 2026-0271

Added to Minute Book

8 Oct 2026

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