2025-0507
1 Sept 2025 · Coroner Ian Potter · Inner North London
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
No concerns could be extracted with a verified quote. Read the original report.
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Although Mr [name redacted] was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730.”
This report
“Such concerns included: the level of detail in observation records not meeting the expectations of the Trust's own policy;”
Identical hazardConfidence 0.90 · high
Earlier report
“However, only one staff member's entries met this expectation. All of the other entries that I was taken to simply recorded [the deceased]'s location at the time of the observation.”
This report
“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;”
Responses
2025-0507-Response-from-East-London-NHS-Foundation-Trust.pdf ↗· East London NHS Foundation Trust