Henok Zaid Gebrsslasie, a 23-year-old patient at the Caludon Centre in Coventry, tragically took his own life on August 12, 2021. The facility, operated by the Coventry and Warwickshire Partnership NHS Trust, is now under scrutiny following revelations of severe lapses in patient care. Mr. Gebrsslasie was found unresponsive in his room shortly after 5:00 PM, having been left unobserved for three hours despite protocols mandating checks every 15 minutes.
Two healthcare workers at the Caludon Centre admitted to falsifying documents to suggest that regular checks had been conducted on Mr. Gebrsslasie. One healthcare worker confessed to having a "habit" of rewriting observation notes to "get out of a situation," while another admitted to a "mistake." Additionally, a healthcare assistant alleged he was instructed by a more senior staff member to alter notes falsely.
The last recorded check on Mr. Gebrsslasie was by student nurse Amy Edwards at approximately 1:55 PM BST, when she was sent to take his blood pressure and temperature. Court proceedings revealed video footage showing Mr. Gebrsslasie sitting on the floor opposite Ms. Edwards during her visit. Ms. Edwards also relayed that Mr. Gebrsslasie expressed a desire "to be left to sleep forever."
"He also said he wanted to be left to sleep forever" – Amy Edwards
In response to the incident, the Coventry and Warwickshire Partnership NHS Trust acknowledged their shortcomings in Mr. Gebrsslasie's care and issued an unreserved apology. The trust stated its commitment to addressing the issues identified in its internal investigation into the death.
The tragic incident highlights significant concerns regarding patient safety and oversight at the healthcare facility. The trust has pledged to implement necessary changes to prevent such occurrences in the future, emphasizing its dedication to learning from this unfortunate event.
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