Under-fire NHS trust recorded patient ate breakfast three days after he died

An NHS mental health trust, recently deemed guilty of significant failings concerning the care of a young patient who ended her own life, has prompted serious concerns over the deaths of 20 other patients over the last decade, reports the BBC.

Coroners have consistently raised issues about the North East London NHS Foundation Trust (NELFT), notably regarding the adequacy of risk assessments and record-keeping.

In some instances, patient records have been found falsified, including one individual recorded as eating breakfast three days after passing away.

A jury at the Old Bailey recently found the trust guilty of health and safety violations related to 22-year-old Alice Figueiredo, who was hospitalized at NELFT’s Goodmayes facility.

This article contains distressing material related to suicide.

Alice, who passed away in 2015, had made 18 attempts to harm herself using plastic bags or bin liners, typically taken from a communal restroom. Despite this, the bags remained available, and the restroom was left unlocked. On her 19th attempt, Alice tragically ended her own life.

The trust was acquitted of the more severe charge of corporate manslaughter.

Following the trial, NELFT expressed its “deepest sympathy for the pain and heartbreak” experienced by Alice’s family over the past decade, stating it would “reflect on the verdict and its implications.” Sentencing is set for September.

The BBC can now disclose that in the decade since Alice’s death, NELFT has faced repeated criticism from coroners regarding lapses in patient care.

Over the past decade, nearly 30 Prevention of Future Deaths (PFD) reports from coroners have cited NELFT.

The BBC has reviewed 20 of these reports, highlighting the most pressing concerns.

In two suicide cases, inquests determined that records had been altered following the deaths.

The most prevalent critique highlighted inadequate or incomplete assessments of the risks patients posed to themselves.

Additional cases spotlighted poor record-keeping, insufficient inter-team communication, staffing shortages, and excessive caseloads.

Two patients who overdosed were documented as being on short-term medication for 18 and 20 years, without any review records.

In response, NELFT has stated it is committed to enhancing “safety and treatment for patients, as well as the experience of families and carers”. The trust claims to be working on improving record-keeping, addressing historic staff shortages, and reforming how staff assess and manage risks, with all inpatient staff receiving training.

Carole Charles, whose husband Winbourne’s case is among the most troubling, emphasized that the Trust must “examine everything”.

Mr. Charles was a patient at Goodmayes Hospital nearly six years after Alice Figueiredo’s demise.

Carole describes him as “a beautiful man, a beautiful soul,” but during the Covid-19 pandemic, the 58-year-old became increasingly despondent.

In her kitchen, she reviews videos and photos of Winbourne. His close childhood friend, Winston Andrews, joins her as they chuckle and reminisce.

“I had never known a time in my life without him,” Winston reflects. “He was more like a brother than a friend.”

However, at the end of 2020, Winbourne’s condition worsened, leading to his admission to Goodmayes Hospital.

Winston noted they believed they had “exhausted every option,” stating, “Perhaps this is the best place for him to seek help.”

On April 10, 2021, five months post-admission, Winbourne took his own life.

Carole and her children had a video call with him the day prior to his passing. She recalls her shock at the news, stating she was “absolutely devastated.” She believed “he was going in there to get better and come home.”

It was not until the inquest that Winbourne’s family and friends became aware of the care deficiencies contributing to his death.

The Prevention of Future Deaths report indicated a psychologist had assessed Winbourne as being at high risk of self-harm. This notation existed in his clinical record but was never reviewed or discussed by the doctors and clinicians managing his care.

The medical team concluded there was “no risk” of self-harm. This led to a reduction in the frequency of staff checks from every 15 minutes to every hour.

Even with this, and contrary to Trust policies, observations for all patients were suspended for an hour on the day of his death. From 16:00 to 17:00, the report states that “all patients subject to general observation on the ward were ignored.”

Winbourne was found shortly after 17:00, about two hours after his last check.

The report mentioned that “staff admitted they panicked.” An alarm was not activated, and doctors were not summoned swiftly. A ligature cutter was locked securely, with no staff member knowing the combination to access it. Moreover, it indicated: “Staff could not or would not provide a coherent and relevant history to paramedics.”

The report also casts doubt on the credibility of Trust staff who provided testimony at the inquest, revealing that observation records appeared to have been fabricated, including three entries made after his death.

“They had noted observations of Winbourne in the day room, sitting and eating breakfast, three days after he had died,” Carole recalls.

“Observations should be done,” stresses Winston. “You fill in the log. Clearly, they didn’t follow protocol.”

Carole and Winston expressed deep shock when one of the staff members who testified via video link attempted to do so from his bed.

“He was actually in bed. My jaw dropped,” Winston noted. “In a nutshell, that illustrated the level of care Winbourne was receiving.”

A second staff member was on the tube heading to catch a flight. In both instances, the family claims the coroner, Graeme Irvine, intervened swiftly.

Mr. Irvine, the senior coroner for East London, concluded that Mr. Charles died by suicide, with neglect contributing to the outcome. He subsequently forwarded his PFD report to the trust and the Department of Health and Social Care to communicate his findings.

NELFT, which offers mental health services to nearly five million residents in north-east London, Essex, Medway, and Kent, employing around 6,500 staff, has stated it “unreservedly apologized” for his death.

It added: “We accepted all findings from the coroner in April 2023, as well as the unacceptable conduct of staff during the inquest.”

The involved staff were managed in accordance with human resources policies and disciplinary procedures, they stated.

The charity Inquest has supported numerous families nationwide who believe their loved ones have been let down by the mental health system. In Ms. Figueiredo’s case, her family spent ten years seeking answers.

Deborah Coles, director of Inquest, commented: “It shouldn’t fall on families to advocate for cultural and policy changes.”

She believes that preventable deaths occur “far too frequently” and trusts must shift away from a culture of defensiveness and denial towards one focused on learning and improvement, prioritizing patient safety.

She expressed hope that the introduction of a new duty of candour, colloquially known as the Hillsborough Law, would facilitate attitudinal changes.

Mrs. Charles, a caregiver for elderly and disabled individuals who understands the care required for vulnerable people, remains doubtful about NELFT’s capacity to learn from the tragic outcomes involving her husband and Alice Figueiredo.

“They keep claiming they’ll change, yet they don’t,” she states. “These are lives that have been lost, leaving families shattered.”