Mahamoud Ali

Private & Confidential  

Ms Saba Naqshbandi KC  
HM Assistant Coroner  
By email only:  

Office of the Chief Medical Officer 
Trust Headquarters 
5th Floor 
9 Alie Street 
London E1 8DE 

Tel: 

E mail: 
Website: www.elft.nhs.uk 

4 September 2024  

Dear Madam  

RE: Regulation 28 Response – Mahamoud Ali  

I am writing on behalf of East London NHS Foundation Trust (‘the Trust’) to 
provide a formal response to the Regulation 28 Notice that you issued following 
the inquest touching the death of Mr Mahamoud Ali, who died in August 2020.   

The Trust extends its most sincere condolences to Mr Ali’s family.  

As you will recall, you heard evidence at the inquest that a member of staff had 
falsified three observations of Mr Ali. You also heard evidence from a senior doctor 
about the steps that the Trust has taken in recent years to reduce the incidence of 
falsified observations.    

The inquest jury concluded that Mr Ali’s death was an accident following falls 
(which took place before his admission to ELFT). Although the jury did not 
conclude that any falsified observations contributed to Mr Ali’s death, the Trust 
acknowledges that you have the legal power to issue a Regulation 28 Notice if you 
have ongoing concerns. In your Notice, you highlighted a concern that the action 
undertaken thus far by the Trust has not been sufficient to ensure that 
observations are being conducted and/or recorded as required.   

 
  
 
 
 
  
   
   
   
   
   
   
   
   
   
   
   
   
   
  
  
  
  
  
  
  
  
  
  
  
   
   
   
   
   
   
   
   
   
 You also noted that the Trust had identified 11 other fatal incidents since August 
2020 where observations may have been falsified. The Trust identified these 
incidents following your request for information about incidents which had taken 
place after Mr Ali’s death in August 2020. In the interests of transparency, I can 
confirm that a further incident has since been identified in this time period, 
occurring on Loxford Ward (Wolfson House) in July 2022, where an observation 
took place but was documented in another staff member’s name.   

In the interests of context, the Trust would like to point out that in some of the 
identified cases the incorrect information that was documented may have been 
through error rather than deliberate falsification, and in some cases it was difficult 
to establish if falsification had taken place at all (such incidents were however 
included out of an abundance of caution when providing data to you and with the 
intent to extract all possible learning from when observations are not undertaken 
as designed).  Notably, even including this extra case, the majority of the identified 
incidents predate the majority of the Trust’s extensive work to improve practice 
around observations.   

Again, in the interests of context, the Trust notes it is unclear if it is 
disproportionately prone to observation records being falsified, or if its 
investigation processes mean that it is better at detecting when this has occurred.  

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. Some are ‘direct’ measures (for example Honesty in Documentation 
training) and some are ‘indirect’ measures (such as escalation protocols where 
there are insufficient staffing resources); in the Trust’s view both are vital in 
reducing the incidence of falsified observations.  

Improvement work already undertaken at the time of writing  

Overarching 
theme   
Staffing/ 
availability   

resource 

Therapeutic  engagement  and  observation  improvement 
work undertaken   
Staff  establishment  reviews  were  undertaken  in  22/23  and 
23/24.  Correct and agreed investments have gone into teams, 
increasing  staff  on  each  shift  by  one  unregistered  Band  3. 
Additional investment has been made for a Band 4 Life Skills 
Recovery  Worker  on  Mondays  to  Fridays  9am  to  5pm  to 
increase  the  delivery  of  activities  and  opportunities  for 
meaningful engagement.   

 
  
 
 
  
  
   
   
   
   
 A  proactive  recruitment  campaign  has  been  ongoing  with 
services moving to zero registered vacancies and a review of 
the unregistered workforce (correct band and skill).   

Staffing rotas for the wards have been reviewed and updated 
to reflect safer staffing requirements; senior approval of rotas 
is  required  six  weeks  in  advance  of  the  current  period  and 
quarterly rota monitoring meetings are in place.   

Escalation  protocols  have  been  developed  for  use  to  guide 
staff when there are not sufficient resources in place to meet 
care needs.   

Staff competency    The Inpatient Safety Suite of training  is now ‘live’ and classed 
as essential for all inpatient nursing staff. This gives the ability 
to  have  oversight  of  compliance  via  Trust-wide  training 
reporting.  This  suite  includes  training  on  observations  and 
honesty in documentation.   

Honesty  in  Documentation  training  was  developed  in  Dec 
2023 and rolled out face to face across all inpatient services 
over the period from December 2023 to April 2024.   

A pilot of Trust-wide clinical induction started in August 2024. 
Prior  to  this,  comprehensive  clinical  inductions  were  being 
done  in  directorates.  This  Trust-wide  approach  supports 
consistency  of  material  and  ensures  core  learning  on 
commencement of clinical roles. Non substantive staff (bank 
staff) are booked to attend and have access to protected study 
time to achieve the same competencies as substantive staff.  

Trust-wide learning lessons seminars open to all staff focus on 
areas of learning and improvement from incidents or identified 
areas of good practice.  

Safety  discussion  sessions  are 
in 
directorates  for  all  inpatient  staff  to  review  observation  data, 
reflect on gaps in practice and disseminate learning.   

facilitated  weekly 

forums 

to  Think 

Time 
in  directorates  are  well 
established.   These  are  held  monthly  in  directorates,  led  by 
lead  nurses  and  are  open  to  all  staff  within  the  inpatient 
service. They are a protected resource for teams to reflect on 
their practice, understand work as it happens using data and 
clinical examples, and generate discussions to inform learning 
and next steps.    

 
  
 
   
   
   
   
  
   
   
 Quality 
improvement   

Standards 
professional 
practice   

to 

A Trust-wide Quality Improvement programme which involved 
all  54  wards,  their  staff  teams  and  service  users  across  the 
Trust,  and  ran  over  a  period  of  18  months,  was  undertaken 
from September 2022 and led to three agreed interventions. 
The  aim  was 
improve  consistency  of  completed 
observations and shift the culture of observation practice. The 
three  change  ideas  agreed  to  move  into  standard  practice 
were:  
 
Board  relay-  this  idea  is  based  on  the  concept  of  a 
baton  relay  –  you  never let  go  of the baton until you  pass  it 
onto  the  next  person.  The  board  relay  is  related  to  general 
observations  and  intermittent  observations  only  and  aims  to 
reduce  the  risk  of  observations  being  missed  and  improve 
handover of clinical information between staff undertaking the 
observations  
 
Twilight shifts- this shift pattern adds an extra member 
of  staff  to  requirements  for a  shift. The hours reflect  periods 
where  there  is  reduced  structured  activity  (after  5PM)  and 
covers the early part of a night shift. Staff undertaking these 
shifts lead on offering therapeutic interventions in the form of 
activities to service users on the ward.   
 
Zonal  observations-  zonal  observations  allows  an
alternative method of observation, which involves designating 
the ward into different zones where allocated staff observe and 
engage with patients individually and as groups for set periods 
of  time.  This  is  to  allow  for  continuous  engagement  with 
patients and monitor environment and patient dynamics over 
a  12hour  shift.  Zonal  observations  can  be  plotted  against 
certain times or functions dependent on the ward layout and 
key tasks relevant to the service user group  

of 

A digital application to document observations (using Microsoft 
PowerApps) has been developed and is in the testing phase. 
It is planned that this will be piloted from October 2024 on four 
wards and then scaled across all inpatient units.   
Expected  standards  of  practice  have  been  communicated  to 
staff, with frequent updates on improvement work since 2021 
to date. In 2023, this specifically addressed accountability and 
responsibility  for  accurately  documenting  observations.  It 
included the importance of honesty in documentation and gave 
guidelines for staff to follow for occasions when observations 
were  missed.  The  Trust-wide  Quality 
Improvement 
programme described above has introduced the observation 
relay  board  to  reduce  incidents  of  observations  being  left  or 
not handed over.   

 
  
 
   
 Audit 
monitoring   

and 

The  Standard  Observation  Measurement  (SOM)  Tool  was 
developed 
for  oversight  of  rates  of  completion  of  all 
observations.  Individual  ward  teams  and  directorates  can 
access and use their data to drive continued improvement.  

Local governance systems exist to ensure changes to practice 
are embedded.    

Ward 
Inpatient 
Safety 
Culture 
Improvement Work   

Night  visits  are  undertaken  by  senior  staff  in  directorates  to 
monitor practice through spot check audits and observing work 
as it happens.    
Since 2023 a new safety culture self-assessment process has 
been  incorporated  into  the  Quality  Assurance  annual  review 
process for each in-patient team across ELFT. Annually, staff 
complete  an  anonymous  survey  based  on  each  component 
safety culture element.  A bespoke team report on the safety 
culture results is then shared back to directorates and teams 
with 
(where 
advice/signposting to where steps can be taken to strengthen 
safety  culture.  The  survey  tool  results  are  then  discussed  in 
team  away-days  and  meetings  with  teams,  enabling  local 
leaders  to  focus  on  areas  where  improvements  need  to  be 
made.  

responses 

received) 

enough 

are 

All of our mental health inpatient wards have been participating 
in  this  process,  with  good  engagement  and  over  800 
responses  have  been  collected  from  across  all  directorates 
and wards.  Next steps are to seek service user perspectives 
to  triangulate  and  strengthen  the  safety  culture  intelligence 
available to the teams.  

The Trust  is involved  in  the  London-wide  Cavendish  Square 
community of practice attended by Chief Nurses (Observation 
practice  is  one  of  its  yearly  objectives)  and  have  applied  to 
enroll  in  a  new  NHS  England  90-day  collaborative  around 
Enhanced Therapeutic observations.  

 
  
 
   
   
   
   
   
   
   
 
 
 
 
 
 
 
 Further planned improvement work   

Areas  for  further 
development   
Staffing/  resource 
availability   

Recommended improvement work   

Continue to review escalation protocols to senior staff on site in 
response  to  changes  in  acuity  or  demand  or  if  there  are  staff 
shortages on a shift.  This is to include:   

Staff 
and capability   

knowledge 

robust 

Task prioritisation and allocation;   
A mechanism for swift deployment of resources to meet 
is 

 
 
demand  and 
compromised.   
To improve the robustness and governance of systems for the 
temporary/bank  nursing  workforce.  This  would  include  better 
training  compliance  and  support  offered 
oversight  of 
(supervision and reflective practice).   

reporting  where  care  delivery 

Professional 
practice   

Continued work on honesty in documentation.    
Review and relaunch use of SOM tool and outputs to impact on 
practice.   

Further explore possible tools for assurance against falsification 
of observation that does not rely on CCTV, although this may be 
difficult  to  design.   This  should  include  a  review  of  national 
improvement workstreams.   

A review of night-shift culture engaging staff and service users 
and  observing  work  as  done.  Design  standards  for  night  shift 
practice and a mechanism for assurance including senior night 
visits.    

A  review  of  findings  from  the  service  user  experience  of 
observations qualitative audit tool.   

The introduction of the Loop App will ensure that only staff with 
the required competencies for each clinical area are able to book 
onto bank shifts.   

Building  on  the  Quality  Improvement  work  around  therapeutic 
engagement  and  observations, 
in  June  2024  ELFT 
commissioned  an  external  Human  Factors  and  Patient  Safety 
Consultant to undertake an analysis of observations practice on 
our  mental  health  In-Patient  Wards  to  better  understand 
observations practice from a human factors/systems approach, 
and to provide redesign ideas to address any gaps, pain points 
and workarounds that exist. Once the work has been completed, 

 
  
 
 
   
   
   
   
  
   
   
   
 senior 
improvements of the Human Factors Analysis work.  

leadership  review  of 

the 

findings  and  suggested 

Communication    To continue the Trust-wide campaign and consistent program of 
communications 
falsification  of 
observations, encouraging honest reporting and improving staff 
awareness of reporting requirements for missed observations.   
To maintain involvement in the Cavendish Square community of 
practice attended by Chief Nurses to develop new approaches 
and adopt learning  

Observation 
practice   

to  staff  discouraging 

the 

Developing  the  second  phase  of  quality  improvement  work  to 
include  collaborative  work  with  the  whole  Multi-Disciplinary 
Team  to  identify  alternatives  to  observations  during  working 
hours.  This would require a significant cultural shift away from 
observations,  which  will  require  a  significant  project  to  be 
undertaken Trust-wide.    

Learning system    To  develop  a  learning  system  that  includes  learning  from 
incidents and improvement work internally, but that also links in 
with national work in relation to observations practice.   

To  design  an  internal  governance  process  for  the  review  of 
reported cases of missed observations and learning that arises 
from  this,  that  will  report  into  the  Patient  Safety  and  Quality 
Assurance committees.    

An  Executive-led  improvement  board  will  monitor  actions  and 
agreed plans.  
To  develop  a  consistent  approach  to  supporting  staff  to  learn
from  incidents  involving  poor  observations  practice  through 
reflection,  personal  accountability  and  if  indicated  onward 
referral to regulatory body. This will be followed in parallel to the 
Trust Disciplinary process.    

Standardised 
processes   

I hope that the above descriptions of work both done and to be done provide you 
and Mr Ali’s family with reassurance that the Trust takes this issue extremely 
seriously and is determined to ensure that observations are being conducted and 
recorded as required.    

Yours sincerely,   

Chief Medical Officer