Dr Minh Alexander retired consultant psychiatrist 29 March 2026
Summary
There is a history of enculturated failure to carry out mental health observations and of falsification of records entries about observations at East London NHS Foundation Trust (ELFT). This is not unique to ELFT but there have been repeated, serious ELFT cases that have been criticised by inquest juries and coroners, which have been publicised. The trust’s reported governance response to these matters is examined here, and FOI material is provided. This includes a disclosed 2024 Human Factors review report commissioned by ELFT to shed light on how failures of observation arise. Supporting coroners’ concerns, the Human Factors review concluded that improvement measures by the trust did not fully address the issues of missed and falsified observations. Via FOIA, the trust reports that it has so far referred twelve staff to the Nursing and Midwifery Council in relation to the falsification of observations. Problems have persisted. As recently as May 2024, staff who were supposed to be conducting 1:1 observations were seated facing away from a patient, whilst using their personal mobile phone. The most recent coroner’s Prevention of Future Deaths warning about falsification of observation records was issued on 1 September 2025 and expressed concern about failure of the trust’s improvement initiatives. The trust countered with its own research evidence to demonstrate improved metrics and asserted that it had already done a “considerable amount of work”. It indicated that it was “reassured that no further action is required”. However, some questions and concerns remain. The Care Quality Commission is currently re-inspecting ELFT and has confirmed that it will take into account issues relevant to a recent coroners’ Prevention of Future Deaths report of 6 February 2026 which criticised ELFT’s serious incident process. In this case, an ELFT investigator had reportedly “neither sought the recollections of treating staff, nor communicated the findings of the report to the same staff”, raising additional concerns about the trust’s governance.
The full report and links to documents can be found here:
RELATED ITEMS
A coroner’s PFD warning of 5 March 2026 revealed serious failures in the mental health care of Nicholas Aina, who killed his mother and seriously injured his sister:
Serious failures by NELFT and ELFT in a mental health homicide: Death of Caroline Adeyelu
Another serious incident took place on ELFT premises on 28 February 2026, at the Tower Hamlets Centre for Mental Health, Mile End Hospital. A patient was attacked by another patient. The victim later died. Police announced on 6 March 2026 that a murder investigation had been opened.
ELFT’s comms over the years have perhaps been glossier than the actuality.
The latest trust Director of Comms was appointed late last year and has previously held central government and parliamentary post. It remains to be seen how trust PR rolls henceforth.
Alexander's Excavations 