Najib Naagi

Trust Headquarters 
4th Floor, East Wing 
St Pancras Hospital 
4 St Pancras Way 
London 
NW1 0PE 

Date: 10th July 2026 

Ms. ME Hassell 
HM senior Coroner 
Inner North London Coroner’s Court 

By email only 

Dear HM Senior Coroner Hassell, 

Re: Inquest touching the death of Najib Ahmed Naagi 

I  write  on  behalf  of  North  London  NHS  Foundation  Trust  (‘The  Trust’)  in  response  to  your  Regulation  28 
Prevention of Future Deaths Report issued on 19th May 2026 following the inquest touching the death of Mr 
Najib Ahmed Naagi.  I would like to express my sincere condolences to Mr Naagi’s family and friends.  The 
matters of concern raised are as follows: 

The clinical support worker responsible for carrying out overnight observations recorded that observations 
had taken place at: 

•  04:30 A.M 
•  05:30 A.M 
•  06:30 A.M 

She repeated these times in both her witness statement and oral evidence to  the court. However, CCTV 
evidence showed observations occurred at: 

 
                                                                                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  04:48 A.M 
•  06:18 A.M 

The support worker only accepted that the records  were inaccurate after being challenged directly  while 
giving evidence.   

The observations in question should have been made every hour, on the half hour, to ensure that Mr Naagi 
was safe and well. The records made did not reflect the actions taken by the support worker. As a result, the 
following specific concerns have been reported: 

1.  The medical record was wrong 
2.  This situation casts doubt on the remainder of the record both in terms of Mr Naagi’s care and the 

care of other individuals 

3.  The court was misled 
4.  Observations  should  be  conducted  when  they  are  meant  to  be  but  if  not,  then  this  fact  must  be 

recorded contemporaneously 

5.  It was put to the court that the number of observations recorded was accurate… which somehow 

made good the lack of earlier observation and corrected the wrongdoing 

6.  The giving of inaccurate evidence may amount to contempt of court and / or perjury and obstructs 

learning from deaths.   

The  Trust  acknowledges  the  gravity  of  the  concerns  being  raised  and  it  recognises  that  these  issues  go 
towards matters of honesty and probity, which are essential for maintaining the public’s trust in the 
medical profession and ensuring the delivery of safe and effective care.  Taking each concern in turn, 
and in this context, I respond as follows:  

1.  The medical record was wrong 

The Trust acknowledges that the medical record was wrong insofar that observations were not undertaken 
at the times recorded.  The Trust’s Supportive Observation and Engagement policy sets out the standards 
expected of staff in relation to record keeping. Specifically, it states that ‘documentation must be done 
immediately when carrying out general observations and staff must only document what they personally 
have observed. No part of the general observation form should be incomplete after a round of general 
observation. Data must not be entered retrospectively, as to do so is falsification of records and therefore 
serious misconduct’. 

 
                                                                                             
 
 
 
 
 
 This guidance is available to all staff, including staff engaged through NHS Professionals (‘NHSP’), as was 
the case in relation to the clinical support worker involved in this incident.  

On 19.05.2026 the Trust referred the clinical support worker to NHSP citing the concerns identified during 
the  inquest  hearing  and  specifically  setting  out  that  she  may  have  acted  dishonestly  by  falsifying  the 
observation  record  and  providing  misleading  evidence  to  the  court  both  in  the  form  of  a  signed  witness 
statement and oral evidence given under oath.   NHSP has conducted a full investigation into the support 
worker’s conduct (which the Trust has had sight of) and a Remedial Mandatory Action Plan has been put in 
place, to include: 

•  Reflective discussion (completed) 
•  Repeat Trust training on observations & a competency check 
•  A records keeping learning exercise 
•  Review of the NHSP Code of Behaviour 

In addition, the support worker has been issued a Standards & Expectations letter, which is the equivalent 
of  a  formal  written  warning.    In  deciding  the  nature  and  extent  of  any  action  to  be  taken,  it  has  been 
recognised  that  the  format  of  the  Trust’s  Observation  Record  Form  does  not  support  staff  to  record 
observations contemporaneously (please see below).  It is understood that this does not absolve the clinical 
support worker from her individual responsibility to uphold professional standards (which she understands) 
but has been considered when determining the degree to which she intended to be misleading.  

2.  This situation casts doubt on the remainder of the record both in terms of Mr Naagi’s care and 

the care of other individuals 

As part of the investigation undertaken by NHSP, the CCTV was reviewed.  This shows that no observations 
were conducted at 05:30. The Trust understands the importance of observations to support safe, person-
centred  care  and  the  formulation  of  risk  assessment.  The  Trust  has  reviewed  observation  competency 
compliance  across  substantive  and  temporary  staff  and  has  reinforced  the  requirement  that  all  staff 
undertaking  supportive  observations  complete  observation  training,  competency  assessment,  and  ward 
induction before undertaking observation duties.  

Compliance  with  observation  practice  and  documentation  standards  will  be  reviewed  through  monthly 
observation audits, Matron quality visits and daily safety huddles, out-of-hours senior manager reviews and 
reporting through the Care Group Quality and Safety governance structure. Any themes and findings will be 
escalated further through the Trust’s governance arrangements where required.  

 
                                                                                             
 
 
 
 
 3.  The Court was misled 

The Observation Record Form in use at the time of this incident consists of a prepopulated form comprising 
of  a  table  with  columns  at  30  minutes  past  each  hour.   It  requires  observations  for  all  patients  to  be 
undertaken at precisely the same time.  There is no space for staff to record the actual time an observation 
is completed, and this means that CCTV evidence often does not align.  If observations are delayed, the form 
itself must be amended  (or annotated)  and guidance to staff regarding what to do  in this situation is not 
clear.  It is believed that the use of this form contributed to the clinical support worker documenting that the 
05:30 observation had been completed at this time, when it had not, and ultimately the court being misled.  
Both the Trust and the clinical support worker acknowledge the seriousness of this situation and wish to 
sincerely apologise in respect of it.   

To reinforce a culture of openness, transparency, and accountability at all times, learning from this case has 
been shared across all inpatient services and management teams. In addition, staff have been reminded of 
their professional responsibilities  when  providing witness statements and evidence during investigations 
and legal processes.  

4.  Observations should be conducted when they are meant to be but, if not, then this fact must be 

recorded contemporaneously 

As explained, the Trust recognises that the existing observation record form does not support staff to record 
observations contemporaneously.  As a result, the Supportive Observations Policy has been amended to 
state that ‘staff must record the exact time that each patient is observed on every check, rather than relying 
solely on the hourly observation column. Accurate timings provide an auditable record of when observations 
took place and are essential for patient safety, incident investigations, CCTV reviews and other reviews of 
care. Recording a time that does not reflect when the observation occurred may constitute falsification of 
records  and  could  result  in  disciplinary  action’.    In  conjunction,  the  general  observation  form  has  been 
amended to allow staff to record the exact time they check each patient. A copy of the revised Supportive 
Observations  Policy  is  attached  to  this  correspondence.    The  updated  observation  form  is  located  at 
Appendix 3.  

5.  It  was  put  to  the  court  that  the  number  of  observations  recorded  was  accurate…  which 

somehow made good the lack of earlier observation and corrected the wrong doing 

The Trust acknowledges that there are no circumstances in which the completion of an observation at 06:18 
can ever be interpreted to represent the completion of an observation required at 05:30 and nowhere in Trust 
policy  is  this  accepted  to  represent  acceptable  practice.    By  referring  the  court  to  the  number  of 
observations completed, the Trust’s Solicitor was not seeking to suggest that the Trust endorses any such 
approach, or in any way makes light of this situation.  This information was provided only to offer a possible 

 
                                                                                             
 
 
 
 
 explanation as to why the clinical support worker maintained that the 05:30 observation was completed.  
Namely,  that  it  was  conceivable  she  was  considerably  mistaken  as  to  its  timing  of  occurrence  and  not 
knowingly seeking to mislead the court. 

6.  That  the giving of  inaccurate  evidence may amount  to contempt  of  court  and  or  perjury  and 

obstructs learning from deaths.   

As  explained  at  the  outset  of  this  Response,  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.    Please be assured that the Trust 
has in place procedures to ensure that, following appropriate investigation, where incidents of this nature 
are established or strongly suspected referrals to regulators, the DBS and / or the police are completed as 
required.  This is to ensure that conduct of this nature is appropriately sanctioned and does not represent a 
continued risk to patient safety. 

I hope that the above response provides assurance that the Trust is committed to providing high quality care 
and  that  this  response  addresses  the  concerns  you  hold.    Please  contact  me  if  you  have  any  remaining 
queries.   

Yours sincerely, 

Chief Medical Officer