Inquest into death of Molly-Star Kirk hears evidence from member of staff at Farndon Unit in Newark

Staff at a mental health facility failed to do the necessary checks before a patient’s death and forged medical observations, an inquest was told.

An inquest explored the circumstances surrounding the death of Molly-Star Kirk, a 20-year-old woman who was found dead in her room at Farndon Unit in Newark on May 29 2022.

The hearing, which began at Nottingham Coroner’s Court on Monday (April 15), has discussed issues with the care given by staff at the facility.

Coroner Laurinda Bower said Molly had been in long term care from 2017 until her death in 2022.

During that time, she attempted suicide several times and was admitted to a number of hospitals across the country including Milton Keynes, London, Maidstone in Kent and Northampton. She became an inpatient in Newark in October 2021.

On day five of the inquest, Farndon Unit staff member Karma Dele Oluoje gave evidence.

Mr Oluoje was a student healthcare assistant at Farndon, while completing his PhD. He joined the clinic on May 8, 2022, without having had previous experience as a healthcare assistant.

He said that despite having received training for his role from his agency, he was not given any training — or talked through any policies — while at Farndon.

The hearing was told that he was working two shifts a week at the time and that he was learning and asking questions throughout the shift.

Mr Oluoje didn’t have access to any log in details for the computer system which would have given him access to patients’ records, their risks and needs and medical history.

He said that the staff members would always attend a handover at the beginning of each shift, which lasted about 15 to 20 minutes, which would allow him to get brief details about the patients rather than all the relevant information.

On the day of Molly’s death, Mr Oluoje was set to observe eight patients, including Molly, between 10am and 11am.

Molly was meant to be checked 12 times an hour, the equivalent of once every five minutes.

When Mr Oluoje took over the observations, he didn’t check if Molly had been to the bathroom or how long she had been asleep.

His observation sheet showed that he completed 12 checks on Molly between 10am and 11am. However, a CCTV camera showed that he only did four checks.

He told the hearing that the CCTV was wrong and the coroner asked if was a “fusion of footage”. He said he had checked on Molly the 12 times written on the observation sheet.

The coroner responded: “Either you have powers of invisibility or you didn’t do the checks.”

After debating whether the footage was wrong, Mr Oluoje admitted that maybe the video was correct and that he didn’t know why or remember why he didn’t do the checks.

The CCTV camera showed that, throughout the hour, he checked Molly for a total of 29 seconds, leaving her unchecked for 16 minutes at times.

Mr Oluoje said that he thought he had done all the necessary checks. However, the CCTV camera revealed that he wasn’t the only member of staff failing to do the necessary checks that day.

The coroner questioned if that was a coincidence or if it was the ward’s culture at Farndon Unit.

Mr Oluoje wasn’t at the mental clinic when Molly was pronounced dead but was informed of it on the day. He said she was alive when he was doing the observations, adding that he was capable of seeing her “breathe up and down” on a two second observation.

Mr Oluoje wasn’t trained to do any mental health observations by his agency or Elysium Healthcare, the company operating the Farndon Unit.

It was only after Molly’s death, that Mr Oluoje was required to sign a document relevant to his competencies to work at the facility. However, the hearing was told that the document was dated prior to the death.

The witness could not say why he didn’t complete the check-ups needed.

The inquest continues.