Barnet Inquest Reveals NHS Trust Flaws After Patient Death

A clinical support worker at a North London NHS Foundation Trust facility in Barnet misled an inquest into the death of Najib Naagi, 55, by exaggerating how often she checked on him. The revelation prompted the Trust to admit systemic failures in its patient observation records and implement sweeping changes to prevent future risks.

Naagi died on 4 January 2025 after being found unresponsive in his bed the previous day. He had been placed on a secure mental health ward due to chronic heart and lung conditions. Staff were required to observe him hourly through a bedroom panel to monitor his breathing and wellbeing.

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CCTV Contradicts Worker’s Claims

Senior Coroner for Inner North London, Mary Hassell, ruled that the worker’s records were inaccurate. CCTV footage showed she checked Naagi only twice in three hours, leaving a 90-minute gap. The worker repeated the false claims in her witness statement and during the inquest, as reported by MyLondon.

Hassell concluded the worker’s actions risked undermining medical staff’s understanding of Naagi’s condition. She also noted the falsification cast doubt on records for other patients and misled the court. The worker did not admit the discrepancy until confronted by the coroner during the hearing.

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Trust Admits Systemic Failures

The Trust’s policy requires staff to record observations immediately and only document what they directly witness. However, its observation form pre-populated check times, forcing staff to amend records retrospectively. This practice contradicted the policy’s prohibition on retrospective entries, which it classifies as serious misconduct.

North London NHS Foundation Trust, which operates 50 mental health and specialist care sites across five north London boroughs, responded to the inquest on 10 July 2026. Its Chief Medical Officer confirmed the Trust had investigated the incident and issued the worker a formal written warning. The worker was placed on a performance improvement plan, requiring retraining, a competency assessment, and a record-keeping 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.

North London NHS Foundation Trust Chief Medical Officer

Policy Overhaul and New Safeguards

The Trust has since revised its observation form to allow staff to record exact check times rather than relying on pre-set intervals. It also updated its policy to mandate precise timings and introduced additional safeguards, including monthly audits of observation records, out-of-hours reviews by senior managers, and daily safety huddles across all wards.

Residents can track the Trust’s progress on these changes through its public governance meetings, held quarterly. The next meeting is scheduled for 5 October 2026 at the Trust’s headquarters in Barnet. Agendas and minutes are published online in advance.

What Happens Next

The clinical support worker remains employed by the Trust but is subject to ongoing monitoring under the performance improvement plan. The Trust has not disclosed whether further disciplinary action is under consideration.

The Trust’s updated observation policy is now in effect across all its facilities. Residents with concerns about care standards can raise them through the Trust’s complaints procedure or contact the Care Quality Commission, the independent regulator for health and social care in England.