NHS Trust Overhauls Patient Checks After Worker Misled Inquest
North London NHS Foundation Trust admits flawed record-keeping system following Najib Naagi’s death in 2025
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A clinical support worker at a North London NHS Foundation Trust mental health hospital misled an inquest into the death of Najib Naagi, 55, by falsely claiming she had checked on him hourly. Naagi died on 4 January 2025 from chronic heart and lung failure after being found unresponsive in his secure ward the previous day. The inquest, concluded in May 2025, ruled his death was from natural causes.
Senior Coroner for Inner North London, Mary Hassell, determined the worker had exaggerated the frequency of her checks. CCTV footage revealed she had observed Naagi only twice in three hours, leaving a 90-minute gap. The worker repeated the inaccurate claim in her witness statement and oral evidence, only admitting the discrepancy when confronted by the coroner during the hearing.
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Trust Admits Flawed Record-Keeping System
The North London NHS Foundation Trust acknowledged its record-keeping system for direct patient observations was flawed. The system required staff to log checks at pre-set intervals, rather than allowing them to record exact times. This policy, the Trust said, risked inaccuracies and could mislead healthcare professionals about a patient’s condition.
The Trust’s policy states that observations must be recorded immediately and only document what staff have directly seen. Retrospective entries are considered falsification of records and serious misconduct. Despite this, the form used by staff pre-populated timings, requiring manual amendments if checks were delayed.
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Worker Disciplined, Policies Revised
In response to the coroner’s findings, the Trust conducted a full investigation. On 10 July 2026, it issued the clinical support worker a formal written warning and placed her on a performance improvement plan. The plan includes repeating observation training, a competency check, and a record-keeping exercise.
The Trust fully accepts the gravity of this situation and that incidents involving significant departures from professional standards of conduct and/or, most significantly, dishonesty can have regulatory and/or legal consequences.
Chief Medical Officer, North London NHS Foundation Trust
The Trust has since revised its observation form to allow staff to record the exact time of each check. It also updated its policy to explicitly require exact timings for all patient observations. Additional measures include monthly observation audits, out-of-hours senior manager reviews, and daily safety huddles across its hospitals.
The North London NHS Foundation Trust provides specialist and mental healthcare across 50 locations in five north London boroughs. It has not disclosed the specific hospital where Naagi was treated, citing patient confidentiality.
What Happens Next
The Trust’s updated observation policies and forms are now in effect. Monthly audits and daily safety reviews will continue as part of the new compliance measures. The clinical support worker remains employed but is subject to ongoing performance monitoring under the improvement plan. No further disciplinary action has been announced.
Questions this report answers
+What did the clinical support worker do wrong?
The worker claimed she checked Najib Naagi hourly, but CCTV showed she checked only twice in three hours. This misleading evidence was repeated in her witness statement and oral testimony during the inquest, risking inaccurate medical records and court proceedings.
+How has the NHS Trust changed its policies?
The Trust revised its observation forms to allow staff to record exact check times, replacing pre-set intervals. It also updated its policy to require exact timings, introduced monthly audits, and implemented daily safety reviews across its hospitals.
+What disciplinary action was taken against the worker?
The clinical support worker received a formal written warning and was placed on a performance improvement plan. This includes repeating observation training, a competency check, and a record-keeping exercise. She remains employed but is under ongoing monitoring.
+Why was the Trust’s record-keeping system considered flawed?
The system pre-populated observation timings, forcing staff to manually amend records if checks were delayed. This risked inaccuracies and retrospective entries, which the Trust’s policy classifies as falsification of records and serious misconduct.
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