Najib Ahmed NAAGI · Prevention of Future Deaths report

On 7 January 2025, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Najib Naagi, aged 55 years. I concluded that inquest on 12 May 2026.

Mr Naagi was found unresponsive in his mental health hospital bed at approximately 7.24am on 3 January 2025. He was resuscitated but died in intensive care the following day. He had been suffering from significant, complex lung disease, but there is no evidence that this developed as a consequence of exposure to asbestos.

His medical cause of death was:

1a acute on chronic cardiorespiratory failure
1b interstitial lung disease of uncertain aetiology in an individual
with a markedly raised body mass index.

I made a determination that death arose from natural causes.

Mr Naagi was on general observations in a secure mental health ward. This meant that a member of staff was meant to look through the observation panel of his bedroom once every hour, on the half hour, to make sure that he was safe and well. The member of staff was required to satisfy themselves that their patient was breathing, and then record the fact of the observation.

The clinical support worker who had been tasked with conducting Mr Naagi’s observations recorded that she had observed Mr Naagi at the following times:

• 4.30am
• 5.30am
• 6.30am

She reiterated that in her statement and in her oral evidence at inquest. She did not volunteer the fact that her record was wrong. It was only when I put it to her in quite robust terms that she accepted this.

In fact, the ward CCTV showed that she looked through the observation panel at the following times:

• 4.48am
• 6.18am

Thus, the record she made did not reflect the actions she took. The consequences of this are as follows:

1. A patient’s medical record was wrong. Any healthcare professional seeking to understand when Mr Naagi had been observed to be well by reading the record would have been given the wrong information.

2. The fact that this record was wrong casts doubt on the remainder of the record, both in terms of this individual (was he actually well at the times recorded?) and the other patients (were they observed when the record indicates that they were observed?).

3. The court was misled.

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

It was put to me by the trust’s solicitor that because the clinical support worker later looked through the observation panel at 6.36am, this meant that the number of observations recorded was accurate and so the later observation somehow made good the lack of earlier observation and corrected the wrong recording. That is simply not the case. Proper patient care demands that patient records are accurate and not in any way fabricated.

Regarding the giving of inaccurate evidence in court, this may amount to a contempt of court, it may amount to perjury, it may be punishable by a fine or even by a term of imprisonment. For your patients, it obstructs learning from deaths.