An inquest into the death of Najib Naagi, 55, led the Trust to admit its record-keeping system for direct observation was flawed and posed a risk to patients
A clinical support worker “misled” an inquest into the death of a London man by exaggerating the number of times she checked on him, a coroner has ruled. Najib Naagi, 55, died in January 2025 from chronic heart and lung failure and interstitial lung disease, an inquest concluded in May.
In his final days, he was placed on a secure ward in an undisclosed mental health hospital belonging to the North London NHS Foundation Trust. Staff were meant to be looking through the observation panel of his bedroom once per hour to ensure his safety and wellbeing, including by checking his breathing.
On January 3, 2025, Mr Naagi was found unresponsive in his bed and resuscitated, but died in intensive care the following day. An inquest into his death established that Mr Naagi died by natural causes.
However, Senior Coroner for Inner North London, Mary Hassell, found evidence that the clinical support worker on shift had “misled” the court and put other patients at risk by incorrectly recording the number of checks she carried out prior to Mr Naagi’s death.
CCTV footage of the ward in fact showed she looked through only twice in three hours, leaving a 90-minute gap between them, but the staff member had repeated this inaccuracy in her witness statement and during oral evidence.
Despite this, the staff member did not admit her record was wrong until the coroner put this to her in “quite robust terms” during the hearing. Ms Hassell concluded that the failure to make consistent records had risked scuppering other healthcare professionals’ understanding of Mr Naagi’s condition, cast doubt on his and other patient’s records, and ultimately misled the court.
The Trust’s own policy states that recordings of this kind must be made “immediately” and staff must only document what they have directly observed. “Data must not be entered retrospectively, as to do so is falsification of records and therefore serious misconduct,” it states.
However, the Trust’s response revealed that its recording form forces staff to log checks at precise, pre-set intervals and not contemporaneously. Recorded timings are pre-populated in the form, with staff expected to amend or annotate the form if their checks are delayed.
Responding to the report on July 10, 2026, the Chief Medical Officer of North London NHS Foundation Trust confirmed it had carried out a full investigation and issued the clinical support worker with a formal written warning. She has also been placed on a formal performance improvement plan, requiring her to repeat observation training, undergo a competency check and complete a record-keeping learning 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,” the official stated.
The Trust, which delivers specialist and mental healthcare at 50 locations across five north London boroughs, confirmed it has since changed the observation form to allow staff to record the exact time they check each patient, and updated its policy to explicitly require exact timings. It has also made sweeping hospital-wide changes to ensure compliance, including monthly observation audits, out-of-hours senior manager reviews and daily “safety huddles”.
Got a story? Email josef.steen@reachplc or @jslondonldr on X.
Stay in the loop with the latest North London news. Sign up to our MyNorthLondon newsletter HERE for daily updates and more.
