NHS mental health trust ‘covered up’ failures to check on father who killed himself

Coroner raised concerns that staff at Goodmayes Hospital had attempted to ‘cover up’ evidence of failures to check on a sectioned father, reports Josh Mellor, Local Democracy Reporter

NELFT’s headquarters in Rainham, Credit: LDRS

Questions remain over whether a mental health hospital trust has learned from the suicide of a Romford father in one of its wards.

Father-of-two Winbourne Charles committed suicide in his room in an acute ward of Goodmayes Hospital on 10th April 2021, having spent five months undergoing treatment for depression with psychotic symptoms.

Following an inquest into Winbourne’s death in April this year, a coroner raised concerns that staff had attempted to “cover up” evidence of failures to check on Winbourne.

Senior coroner for East London Graeme Irvine said that in three internal reports written in the days after Winbourne’s death, North London NHS Foundation Trust (NELFT) failed to acknowledge a “smoking gun” of missed observations and described a “culture of impunity” on the ward.

The coroner’s concerns were highlighted in a public report that warned of a risk of future deaths at the trust.  In response NELFT came up with an “action plan” outlining what changes it would put in place.

The action plan – which both NELFT and the chief coroner declined to publish for two months – says some of the nursing staff who allegedly wrote “factually inaccurate” records have been referred to the Nursing and Midwifery Council.

It has also changed how it investigates patient safety incidents, which will need to be signed off by a new panel.

However, NELFT board member Mark Friend pointed out that the allegation of a “cover up” is not addressed in the action plan.

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Speaking at the trust’s public board meeting last week, Friend, a non-executive director, said: “I’m very disturbed by what appears to be an attempt to cover up in the 72-hour report.

“It’s a signal there of something that’s not falling into line and that something’s wrong.”

Chief nurse Wellington Makala said NELFT has promised Winbourne’s family there would be “changes in the way that we would do things”.

A key concern raised in the inquest was that three nurses had refused to answer questions about the reliability of their observation notes – some of which were completed two days after his death – by citing an inquest rule which allows witnesses to protect themselves from self-incrimination.

Makala, who called the inquest “one of the most difficult” he had ever done, asked: “What does that say to the family? 

“What I am trying to bring to the board is an issue around culture.

“If I start not being able to trust what nurses say they have done, if I start questioning honesty as a nurse then that process becomes difficult.”

Makala told the board he has carried out a “thematic review” of suicides of patients under the trust’s care in the last five years, as well as all serious incidents and coroners reports.

He outlined ten “learning themes” that include the trust’s risk assessments of patients, quality of record keeping, joint-working with other health bodies, workforce shortages and high caseloads.

To tackle issues with a “closed culture”, the chief nurse said the trust has “moved staff around” and has been working on instilling a more “compassionate culture” for the last two years.

The chief coroner was contacted for comment but did not respond in time for publication.

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