Staff slept while patient killed at NHS mental health unit

Staff slept while patient killed at NHS mental health unit Hugo’s father, William Flint Cahan, who has attended each session of the inquest with different household members, said determination was "complacency" by staff, arsenic good arsenic a deficiency of care. He maintains his son's decease was "preventable had the level of attraction been arsenic it should person been." Hugo’s brother, Jolyon, an NHS doctor, described the "litany of failures, some incompetence and dishonesty, that pervaded the attraction of some patients was harrowing." Over the past 12 years, section coroners have issued at least 29 Prevention of Future Deaths (PFD) notices to the Trust. These notices are sent when a coroner identifies problems that, if left unaddressed, could lead to further deaths. The BBC’s analysis of the reports covering diligent and assemblage services found that in more than half of the cases there had been a failure to properly assess the risk the patient posed to themselves or others. Poor communication between staff, other agencies and families was repeatedly highlighted. The most serious warnings concerned poorly conducted observations and falsified records—basic attraction required to keep patients safe. A 2021 study by the coroner who oversaw the Flint Cahan inquest warned that "a civilization of impunity existed" at the Trust where "inaccurate and misleading signaling of objective records was tolerated." In 2024, two additional reports noted missed observations and records that had been falsified to suggest patients had been checked. In response to one of the PFD notices, the Trust said it had introduced extended grooming programmes and prime checks. In 2025, a fourth report into the death of a young woman again highlighted falsified reflection records. The coroner stated, "despite assurances" from the Trust successful galore enactment plans", the inquest had "revealed wide concerns" astir however observations were carried retired crossed 2 wards." Other significant concerns raised in the reports include how units responded to emergencies, with delays in resuscitation and, on one occasion, nursing staff administering chest compressions to a patient’s abdomen instead of the chest. Brian Dow of the mental‑health charity Rethink is calling for a national registry of patient information to monitor the quality of care provided by mental‑health units across the country. "We person been present before" with mediocre observations, records being falsified and unacceptable care, he says. "We person got to person a amended attack to diligent information successful what are the astir hard and astir susceptible wards with the radical who are the astir unwell."