Najib Naagi: Prevention of future deaths report

You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 July 2026.  I, the coroner, may extend the period if an appropriate application is made. 

I have a duty to send a copy of your response to the Chief Coroner.
In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. 

Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. 

The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages  
Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary. 

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.

The MATTERS OF CONCERN are as follows:
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. 

I also may send a copy of the report to any other person who I believe may find it useful or of interest. 

I have sent the report to:
The daughter of Najib Naagi

I also have a duty to send a copy of the report to the Chief Coroner.

You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026).          Any representations will be sent to the Chief Coroner alongside  the  report.  Please  refer  to  box  5  above  for  additional information relating to the publication of reports and responses.