An inquest into the death of a 20-year-old woman at a Newark mental health unit has been told there was a culture on a ward of falsifying medical records.
Healthcare assistant Ebo Ahon was giving evidence on day eight of the inquest into Molly-Star Kirk, who was found dead in her room at Farndon Unit in Newark on May 29, 2022.
It was revealed that the required mental health observations were not carried out but also that the documents were often falsified and rewritten.
Coroner Laurinda Bower told the hearing at Nottingham Coroner’s Court that Molly had been in long term care from 2017 until her death and had been a patient in Newark in October 2021.
Ebo Ahon was called to give evidence as he was working on the day of Molly’s death, having been the one to find her and ring the alarm.
Mr Ahon started working at Farndon Unit in late October 2021 without previous mental health training and was doing an average of four shifts a week. He said he didn’t receive any training from Elysium and that his induction knowledge was mainly from shadowing other colleagues.
He wasn’t given any of the company policies and was put into mental health observations straight away.
On his competencies checklist, it states that he has completed several courses, which Mr Ahon denies, saying that he doesn’t recall doing so, including mental health observations.
The document also states that it was signed by the healthcare assistant on November 5, which he denies as that was his first shift at Aster Ward and it was a night shift.
He said that the document’s date was forged, claiming that it is false and he had never done that.
Mr Ahon said that he had been asked to rewrite patients’ observation sheets before as staff from other wards would help in the morning when Aster Ward was short-staffed and would get the patients mixed up.
“This means that these observations checklists were literally just a tick-box exercise that just makes it look like the forms have been filled in properly, whether the right checks have been done on the right patients or not,” said the coroner.
She added: “You are not remedying the fact that the wrong checks have been done, you are just making the form look like the problem didn’t happen.”
The coroner described the method of filling the observation sheets in blocks, correcting errors and rewriting the sheets “unsafe” as it affected patients’ medical records.
Mr Ahon admitted as previous staff members at the unit who provided evidence, that it was a culture of practice at Elysium to continually not do the checks but fill in the observation sheet to make it seem like it happened.
It was also found that Mr Ahon was using other patients’ sheets, crossing their names and room numbers, and using Molly’s details as they ran out of sheets and often filled in slots on the observation sheet for his colleagues who were meant to be doing the checks to make it seem like they did.
“Because it was what everyone was doing, I didn’t think it was wrong,” said Mr Ahon.
On the day of Molly’s death, May 29, Mr Ahon was set to observe eight patients, including Molly, between 11am and noon.
Molly was meant to be checked 12 times an hour, the equivalent of once every five minutes, which the observation sheet shows to have been completed, however, CCTV footage revealed that only three checks were completed.
Two of those checks were completed by his colleague Joel Davies.
Around 9.01am on the day of Molly’s, Mr Ahon and colleague Tamzin Brentall entered Molly’s room to wake her up to get her medication.
Mr Ahon said he tapped Molly on the right shoulder and shouted her name but there was no reply. However, he then said that she told him that she didn’t want the medication.
During his observation period, Mr Ahon only conducted the first check on Molly 37 minutes after she was last checked. The check only lasted two seconds, which he admitted to be unacceptable.
“At the time it felt like 10 seconds,” said Mr Ahon.
After that he returned to the lounge to socialise with other staff members, which the coroner described as a common and unsafe practice.
“You had the busy task of falsifying records to make it look like you have done the checks,” said the coroner.
Mr Ahon was meant to do observations again between 2pm and 3pm. However, the inquest was told someone else signed his name on the form to make it look like he did it between 2pm and 210pm.
He checked on Molly at 2.30pm and couldn’t confirm through the room’s window if she was breathing so entered the room, describing the 20-year-old skin as being blue and grey.
Mr Ahon made a call to 999 to report Molly’s unresponsive state, which was played in court and showed that he was unsure about Molly’s age. The dispatcher asked several times if Molly was breathing, if CPR was taking place, if there was a defibrillator at the unit, but the responses were vague or none at all.
Within the first five minutes of discovering Molly wasn’t breathing, no one did CPR or used a defibrillator during the first 16 minutes.
Paramedics first arrived at 14.46pm, however, Molly was pronounced dead at 3.18pm.
The inquest continues.
