Prevention of future deaths report: Mahamoud Ali (31 July 2024)

Summary

Mahamoud Hussain Ali fell in the street and was taken by ambulance to Homerton University Hospital. He discharged himself but was later readmitted after another fall on the same day.

Subsequently, he was detained under section 2 of the Mental Health Act 1983 and transferred to Lea Ward, Mile End Mental Health Hospital. He was placed in isolation and assigned to be under observation every 15 minutes. On the 21 August 2020 at around 18:00 he was found unresponsive on the floor of his room. Following this he was taken to Royal London Hospital and died on 26 August 2020 at the Royal London Hospital.

Looking into this case, the Coroner has stated that staff at East London Foundation Trust had falsified observation records. The report also notes that investigations commissioned by Trust following Mr Ali’s death uncovered 11 further “fatal incidents” where records may have been fabricated.

Content

The Coroner set out their matters of concern as follows:

• Although Mr Ali 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 Ali was asleep.
• Evidence has been provided by the Trust that since Mr Ali’s 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 Ali was detained.
• Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation. 
• The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022.  
• The Coroner has been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorates in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…”  
• Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done.” 
• Given the above, the Coroner is 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.