Under-Fire NHS Trust recorded a breakfast with breakfast three days after his death

An NHS Mental Health Trust, recently found guilty of serious failures in the care of a young patient who committed suicide, has raised serious concerns concerning the death of 20 other patients in the past 10 years, the BBC revealed.

The coroners have repeatedly highlighted problems concerning the North East London NHS Foundation Trust (NELFT), including on the quality of risk assessments and registry.

In two cases, the patients’ ratings were falsified. Including a man who was recorded as having breakfast three days after his death.

An old Bailey jury last week recognized the trust guilty of health and security violations in Alice Figueired, 22, who was hospital at the Goodmayes hospital in Nelft.

This article contains a painful material linked to suicide.

Alice, who died in 2015, tried to injure herself 18 times using plastic bags or pads, often taken from the same common toilets. Despite this, the bags were not removed and the toilets were unlocked. The 19th opportunity, Alice committed suicide.

The trust was authorized for the more serious accusation of guilty manslaughter.

After the trial, Nelft said that he had extended his “deeper sympathy for pain and sorrow” that his family had suffered in the past 10 years, saying that she “would examine the verdict and her implications”. He will be sentenced in September.

The BBC can now reveal during the decade since Alice’s death, Nelft has been criticized several times by coroners for failures in patient care.

Over the past decade, nearly 30 future death prevention reports (PFD) of the Coroners have mentioned NELFT.

Among these, the BBC analyzed 20 which raise the most serious concerns.

In two cases where patients followed their lives, investigations concluded that files had been modified after their death.

The most common criticism revealed that the risk assessment that patients posed by themselves were mediocre or incomplete.

The cases also highlighted poor files, a lack of communication between teams, staff shortages and high workloads.

Two patients who died of overdoses have been on short -term medicines for 18 years and 20 years, without any file having been examined.

In response, NELFT says that it continuously improves “safety and treatment for patients, as well as the experience of families and caregivers”. He also indicates that he improves the holding of registers, addresses the historical shortages of the staff and modifies the way in which the staff assesses and manages the risks, all the members of hospital staff according to training.

Carole Charles, whose case of Winbourne husband is one of the most disturbing, said that the necessary confidence “to look at everything”.

Charles was patient at GoodMayes hospital almost six years after Alice Figueiredo’s death.

Carole describes him as “a handsome man, a beautiful soul”, but during the cocovid-19 pandemic, the 58-year-old man became more and more depressed.

Sitting in her kitchen, she watches videos and photos of Winbourne. Her close childhood friend, Winston Andrews, sits alongside her as they laugh and smile at memories.

“I had never known part of my life when it was not,” said Winston. “He was a brother rather than a friend.”

But at the end of 2020, Winbourne became so sick that he was admitted to the Goodmayes hospital.

Winston says they all felt that they had “tried everything”, adding: “So maybe it’s the right place for him, to try to get help.”

On April 10, 2021, five months after being admitted to the hospital, Winbourne committed suicide.

Carole and her children told her about a video call the day before. She describes her shock by the news, saying that she was “absolutely devastated”. She had thought “he went there to improve and go home”.

It was only during his investigation that Winbourne’s family and friends discovered the failures of care that contributed to his death.

The report on the prevention of future deaths indicates that a psychologist assessed Winbourne as at high risk of injuring himself. It was on his clinical file, but he was not read or discussed by the team of doctors and other clinicians supervising his treatment.

They concluded that there was “no risk” of himself. The family says that this meant that observations or checks on them by the staff have been reduced from every 15 minutes to an hour.

Even then, and against the policy of confidence, the observations were stopped for all the patients for an hour on the day of his death. Between 4:00 p.m. and 5:00 p.m., the report indicates that “all the patients subject to a general observation in the neighborhood have been ignored”.

Winbourne was discovered shortly after 5:00 p.m., about two hours after its last verification.

The report indicates that “the staff agreed that he panicked”. The alarm bell did not sound and the doctors were not called quickly. A ligature cutter was locked in a box and no one knew that the combination unlocks him. He also says: “The staff could not or would not provide a clear and relevant story for paramedical paramedics.”

The report calls into question the credibility of the trust staff who testified to the investigation. He indicates that the observation files seemed to have been cut and glued, including three entries which were made after his death.

“They had written Winbourne observations in the day room, sitting there eating breakfast, and it was three days after her death,” said Carole.

“The key to observations is that you really make the observations,” explains Winston. “You fill the newspaper. Obviously, they had not done so.”

Carole and Winston also say that they were deeply shocked when one of the staff members who testified by Video Link tried to do it from her bed.

“He was actually in bed. My mouth fell,” said Winston. “In a microcosm that showed me what kind of Winbourne care received.”

A second staff member was on the tube in mind to take a flight. In both cases, the family says that the coroner, Graeme Irvine, intervened quickly.

Mr. Irvine, a senior coroner for eastern London, concluded that Mr. Charles had died of suicide, contributed to negligence. He sent his VFI report to the Trust and the Ministry of Health and Social Coins to emphasize what he had found.

NELFT, which provides mental health services to nearly five million people living in northeast London, Essex, Medway and Kent and employs around 6,500 employees, said it “apologized without reservation” for its death.

He added: “We accepted all the coroner’s conclusions in April 2023, as well as the unacceptable behavior of the survey staff.”

These staff members have been managed in accordance with human resources policies and disciplinary procedures, he said.

The charitable organization, survey, has supported many families across the country who believe that their loved ones failed by the mental health system. In the case of Ms. Figueiredo, his family spent 10 years fighting to get answers.

The director of the investigation, Deborah Coles, said: “He should not be due to families to have to fight for cultural and political change.”

She said that she believed that avoidable deaths occurred “too often” and that confidence should “move away from a culture of defensive and denial and concealment” to that which is concerned about learning and improving and protecting patients.

She said that she hoped that the plans for a new deductible duty, known as the law of Hillsborough, would change attitudes.

Charles, who was a worker for care for the elderly and disabled and says that she knows what care is necessary when people are vulnerable, remains skeptical about whether Nelft will learn from the death of patients like her husband and Alice Figueedo.

“They continue to say that they will change and they don’t do it,” she said. “It is the life of people who are taken. This leaves the families devastated.”