Recurance · prevention of future deaths reports
Pre-inquest brief
Inaccurate or falsified patient observations
The earlier warning
Mahamoud Ali · 10 Jul 2024 · Saba Naqshbandi, Inner North London
“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.”
judiciary.uk/…/mahamoud-ali-prevention-of-future-death-report
What was promised
Stated action 1 · response to Mahamoud Ali (10 Jul 2024) · stated timescale: 2023
“The Trust has considered your Notice extremely carefully. As well as setting out the steps that the Trust has already taken in this area (for the benefit of those who did not attend the inquest but have an interest in this matter), this response will also set out the further steps that the Trust has taken since 2023 and are looking to enact.”
Stated action 2 · response to Anna Elliott (18 Jul 2024) · stated timescale: 2024-09-30
“The Tower Hamlets Crisis Services acknowledge that on 23 November 2021 the calls made by Ms [name redacted] mother to the Home Treatment Team (HTT) were not recorded in the RiO medical records or passed on. 6. Steps are now in place to ensure calls are not missed: the administrators' office will now be covered with admin staff during the team handover from 14:00 to 16:00 to ensure calls are not missed. 7. In addition, HTT staff will be offering carers and significant others a check-in/follow up call for”
What recurred
- 18 Jul 2024 · Anna Elliott · Melanie Lee
- 1 Sept 2025 · 2025-0507 · Ian Potter · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Mahamoud Ali · 10 Jul 2024
“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.”
Later · 2025-0507 · 1 Sept 2025
“Such concerns included: the level of detail in observation records not meeting the expectations of the Trust's own policy;”
What happened next
No web check of the stated actions has been published for this chain.