Rose Forster’s death from pneumonia in April 2023 at Newham Mental Health Centre in east London has been linked to neglect and falsification of medical records, according to an inquest ruling and subsequent investigations. The case has raised concerns over care standards at the hospital, which has faced similar issues previously.

Rose, 61, was a patient at the centre for six weeks, initially detained under the Mental Health Act for four weeks before becoming an informal patient. During this period, her mental health reportedly improved, but her physical condition deteriorated. On April 16, her daughter Karen Forster, who had been a caregiver since her mother was diagnosed with paranoid schizophrenia following a traumatic assault in Uganda, noticed Rose struggling to breathe during a visit in the afternoon.

Karen raised her concerns with nurse Rosemary Chukwuji-Ohanachum, who denied a conversation took place, though CCTV footage later confirmed the interaction. Despite apparent breathing difficulties, Rose was reported to have received medication and hourly observations, but CCTV contradicted these records. Nurses documented administering medication and conducting regular checks, but video evidence showed neither occurred as stated.

Around 8 p.m., a nurse signed off on Rose having been observed hourly, although the footage revealed no visits to her room between 7:30 p.m. and 9 p.m. Later that evening, Rose suffered cardiac arrest; staff delayed calling an ambulance for approximately 20 minutes. She was transported to accident and emergency but died in the early hours of April 17 with her daughters present.

The serious incident report by the trust highlighted discrepancies between staff documentation and CCTV, noting vital signs such as blood pressure and heart rate had not been monitored consistently. These omissions potentially delayed recognition of Rose’s pneumonia, though it remains unclear if the infection was hospital-acquired.

The coroner concluded that neglect on the ward had directly contributed to Rose Forster’s death. The trust subsequently paid £45,000 in compensation to the family. Karen Forster described a broader culture of dishonesty and cover-up at the hospital, citing 29 prevention of future death reports issued to the trust over the past 12 years for similar incidents.

Chukwuji-Ohanachum was the nurse on duty during the final hours of both Rose Forster and Hugo Flint Cahan, a 34-year-old patient who was fatally strangled by another patient at the same facility three months earlier. In an earlier inquest related to Flint Cahan’s death, the coroner noted recurring errors and falsified records within the trust’s mental health wards, warning that these issues were repeatedly appearing without adequate resolution.

The trust’s chief nurse, Claire McKenna, expressed deep regret over the failures in care and affirmed that significant changes were being implemented to improve inpatient practices and culture. Chukwuji-Ohanachum remains employed by the trust but is currently not working pending further investigation.