Health workers falsified checks of man found dead

Mental health facility staff who failed to check on a patient falsified paperwork to make it look as though observations had been carried out, an inquest has heard.

Henok Zaid Gebrsslasie died while under the care of the Caludon Centre in Coventry on 12 August 2021.

The 23-year-old should have been checked every 15 minutes but was left unobserved for three hours, a court heard.

One healthcare worker said she had a "habit" of rewriting observation notes "to get out of a situation" with another telling the court he was directed to falsify notes by a more senior member of staff.

Jurors at the inquest heard the checks failed to be carried out between 14:00 and 17:00 on 12 August.

Mr Gebrsslasie died shortly after 14:00, the court heard.

Asked why she had failed to conduct observation checks between 15:00 and 16:00, healthcare assistant Ana Adeyemo said she had been delayed in finishing her previous observation checks.

She described to the court how, when she was on her way to check her next duties, a patient had asked her to visit the laundry.

"When I came back to the office, towards the end of the hour and checked the board, I realised I was meant to do the Level 2 observations," she said.

She then described "rewriting" the paperwork to make it look as though the patients, including Mr Gebrsslasie, had been checked, but had "mistakenly" filled in the wrong retrospective entries as a worker had also neglected to make checks in the previous hour.

The next health worker due to make the observations on the psychiatric intensive care unit ward said he had become distracted by patients as he was the "only member of staff on the floor".

Healthcare assistant Biju Abraham was due to carry out the checks between 16:00 and 17:00.

After looking after a patient in seclusion until 16:00 he said "persistent patients" had asked him to take them on a cigarette break.

"I am the only one of the staff on the floor at the time, so I thought I must be on floating duties, so I took them out to the courtyard," Mr Abraham said.

He then went to the laundry and took patients on another cigarette break before checking the observation board in the staff room shortly before 17:00, and realising he should have been carrying out the 15 minute checks.

Setting off to carry out the checks he was one of the first to find Mr Gebrsslasie unresponsive in his room, describing to the court how it had left him traumatised.

"I was really panicked because I thought it was [during] my observation delay that it happened," he said.

He said that he had flagged his missed observations and associated paperwork to a psychiatric nurse on duty at the time, Beth Rapson, who told him to retrospectively fill out the missing observation information.

He said he was in "panic mode" and not "functioning at the time," but had filled in the sheets "because she's a senior member of the staff".

The court heard in earlier evidence from Ms Rapson that she denied directing the worker to falsify the documents.

The court also heard evidence that workers had flagged up staffing levels as a problem on the ward on the day, but an "appropriate" level had been in place according to Sandra Barnes, matron of the Coventry and Warwickshire Partnership NHS Trust facility.

The inquest continues.

Follow BBC Coventry & Warwickshire on BBC Sounds, Facebook, X and Instagram.