Under-fire Nhs Trust Recorded Patient Ate Breakfast Three Days After He Died

An NHS intelligence wellness trust, precocious recovered blameworthy of superior failings successful nan attraction of a young diligent who took her ain life, has had superior concerns raised complete nan deaths of 20 different patients complete nan past 10 years, nan BBC has found.

Coroners person many times highlighted issues astir nan North East London NHS Foundation Trust (NELFT), including astir nan value of consequence assessments and record-keeping.

In 2 cases diligent notes were recovered to person been falsified. Including 1 man who was recorded arsenic eating meal 3 days aft he had died.

An Old Bailey assemblage past week recovered nan spot blameworthy of wellness and information breaches successful nan attraction of 22-year-old Alice Figueiredo who was an inpatient astatine NELFT's Goodmayes hospital.

This article contains distressing worldly related to suicide.

Alice, who died successful 2015, had attempted to harm herself connected 18 occasions utilizing integrative bags aliases bin liners, often taken from nan aforesaid communal toilet. Despite this, nan bags were not removed, and nan toilet was near unlocked. On nan 19th juncture Alice took her ain life.

The spot was cleared of nan much superior complaint of firm manslaughter.

After nan trial, NELFT said it extended its "deepest sympathy for nan symptom and heartbreak" her family had suffered complete nan past 10 years, saying that it would "consider nan verdict and its implications". It will beryllium sentenced successful September.

The BBC tin now uncover successful nan decade since Alice's death, NELFT has been many times criticised by coroners for failures successful diligent care.

In nan past decade, astir 30 prevention of early deaths (PFD) reports from coroners person mentioned NELFT.

Of these, nan BBC has analysed 20 which raise nan astir superior concerns.

In 2 cases wherever patients took their ain lives inquests concluded records had been altered aft their deaths.

The astir communal disapproval recovered nan appraisal of nan consequence patients posed to themselves was mediocre aliases incomplete.

Cases besides highlighted mediocre record-keeping, a deficiency of connection betwixt teams, unit shortages and precocious caseloads.

Two patients who died of overdoses were said to person been connected short-term medicine for 18 years and 20 years, pinch nary grounds of that having been reviewed.

In response, NELFT says it is continually improving "safety and curen for patients, arsenic good arsenic nan acquisition of families and carers". It besides says it is improving record-keeping, tackling humanities unit shortages and changing nan measurement unit measure and negociate risk, pinch each in-patient unit undergoing training.

Carole Charles, whose hubby Winbourne's lawsuit is 1 of nan astir disturbing, said nan Trust needed "to look astatine everything".

Mr Charles was a diligent astatine Goodmayes infirmary astir six years aft Alice Figueiredo's death.

Carole describes him arsenic "a beautiful man, a beautiful soul", but during nan Covid-19 pandemic, nan 58-year-old became progressively depressed.

Sitting successful her kitchen, she is looking astatine videos and photos of Winbourne. His adjacent puerility friend, Winston Andrews, is sitting alongside her arsenic they laughter and grin astatine nan memories.

"I had ne'er known a portion of my life erstwhile he wasn't successful it," Winston says. "He was a relative alternatively than a friend."

But astatine nan extremity of 2020, Winbourne became truthful unwell he was admitted to Goodmayes Hospital.

Winston says they each felt they had "tried everything", adding: "So possibly it is nan correct spot for him to be, to effort and get immoderate help."

On 10 April 2021, 5 months aft being admitted to nan hospital, Winbourne took his ain life.

Carole and her children had spoken to him connected a video telephone nan time before. She describes her daze astatine nan news, saying she was "absolutely devastated". She had thought "he was going successful location to get amended and travel home".

Only astatine his inquest did Winbourne's family and friends observe nan failures successful attraction which contributed to his death.

The Prevention of Future Deaths study says a scientist assessed Winbourne arsenic being astatine precocious consequence of harming himself. This was connected his objective record, but it was not publication aliases discussed by nan squad of doctors and different clinicians overseeing his treatment.

They concluded location was "no risk" of him self-harming. The family says it meant nan observations aliases checks connected him made by unit were reduced from each 15 minutes to 1 an hour.

Even then, and against Trust policy, observations were stopped for each patients for an hr connected nan time he died. Between 16:00 and 17:00, nan study says "all patients taxable to wide study connected nan ward were ignored".

Winbourne was discovered soon aft 17:00, astir 2 hours aft he was past checked.

The study says "staff agreed they panicked". The siren doorbell was not sounded and doctors were not called promptly. A ligature cutter was locked successful a container and nary 1 knew nan operation to unlock it. It besides says: "Staff could not aliases would not supply a clear and applicable history to paramedics."

The study questions nan credibility of nan Trust unit who gave grounds to nan inquest. It says study records appeared to person been trim and pasted, including 3 entries that were made aft he had died.

"They'd written observations of Winbourne being successful nan time room, sitting location eating his breakfast, and this was 3 days aft he'd passed away," says Carole.

"Key to nan observations is that you really do nan observations," says Winston. "You capable successful nan log. Clearly, they hadn't done it."

Carole and Winston besides opportunity they were profoundly shocked erstwhile 1 of nan unit members who gave grounds by video link, tried to do this from his bed.

"He was really successful bed. My rima dropped," says Winston. "In a microcosm that showed maine what benignant of attraction Winbourne was getting."

A 2nd unit personnel was connected nan conduit heading to drawback a flight. In some cases nan family says nan coroner, Graeme Irvine, intervened quickly.

Mr Irvine, elder coroner for eastbound London, concluded Mr Charles had died from suicide, contributed to by neglect. He sent his PFD study to nan spot and nan Department of Health and Social Care to item what he had found.

NELFT, which provides intelligence wellness services for astir 5 cardinal group surviving successful north-east London, Essex, Medway and Kent and employs astir 6,500 staff, said it "apologised unreservedly" for his death.

It added: "We accepted each nan findings from nan coroner successful April 2023, arsenic good arsenic nan unacceptable behaviour of unit astatine nan inquest."

Those unit were managed successful statement pinch quality resources policies and disciplinary procedures, it said.

The charity, Inquest, has provided support for galore families astir nan state who judge their loved ones person been grounded by nan intelligence wellness system. In Ms Figueiredo's case, her family spent 10 years fighting to get answers.

Inquest's director, Deborah Coles, said: "It should not beryllium down to families to person to conflict for taste and argumentation change."

She said she believed avoidable deaths were happening "far excessively often" and trusts should "move distant from a civilization of defensiveness and denial and cover-up" to 1 that is concerned astir learning and betterment and protecting patients.

She said she hoped plans for a caller work of candour, known arsenic the Hillsborough Law, would alteration attitudes.

Mrs Charles, who has been a attraction worker for older and abnormal group and says she knows what attraction is needed erstwhile group are vulnerable, remains sceptical astir whether NELFT will study from nan deaths of patients for illustration her hubby and Alice Figueiredo.

"They support saying they are going to alteration and they don't," she says. "These are people's lives which are taken. It leaves families devastated."