Mahamoud Ali

1. 1. falsified observation records

   “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. She then completed it as if she had conducted those observations, recording that Mr [name redacted] was asleep.”

2. 2. falsified observation records leading to deaths

   “Evidence has been provided by the Trust that since Mr [name redacted] death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted. One of these, in May 2023, was in Lea Ward, the same ward where Mr [name redacted] was detained.”

3. 3. falsified observation records

   “I have been provided with evidence that in October 2023, the Trust wrote to staff about 'Falsification of Observation Records', stating:”

4. 4. future deaths due to inadequate observation practices

   “Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur.”

Linked reports