Staff at a mental health hospital who faked records of observations on a vulnerable patient on the night of his death were regularly "encouraged" to do so, an inquest has heard.

Nurses at Northgate Hospital in Great Yarmouth made a record of regular check-ups on 48-year-old Eliot Harris in the hours leading up to his death, in the early hours of April 10, 2020.

However, at an inquest into his death, it emerged that not all of the observations recorded had taken place.

Mr Harris, who was diagnosed as schizophrenic and lived in Elsenham House care home in Cromer, was admitted to the hospital on April 6, after being assessed under the mental health act.

He was found unresponsive in his ward bedroom at around 1.30am on April 10 and his death was confirmed shortly after 2pm.

The cause of his death remains a mystery, but the 11-day inquest has highlighted a number of issues relating to his care, including a "culture" at the hospital whereby records of check-ups were either filled in retrospectively - sometimes by days - or even falsified.

The Norfolk and Suffolk NHS Foundation Trust, which runs the hospital, dismissed three members of staff after internally investigating the incident and insists changes have been made as a result of it.

But senior coroner Jacqueline Lake said she still had concerns that some two years later, many of the issues with Mr Harris' care still plague the Trust.

She said: "I have heard evidence on behalf of the Trust and am satisfied that several steps have been taken with a view of preventing future deaths."

However, she said she continued to have concerns about the quality and detail of observations being carried out.

She said: "I am concerned that problems arising in Eliot's case are still ongoing some two years later."

The coroner said she would be preparing a report to prevent future deaths which would also highlight a range of other concerns, including how confident staff feel going into patient rooms in emergencies and into the Trust's record-keeping.

The inquest heard how during his time at the hospital, Mr Harris regularly refused oral medication and was only willing to eat cheese sandwiches - declining all other food.

Throughout the evening of April 9, observations were recorded for him four times per hour, with Mr Harris last seen awake at 6.10pm.

Each record marked him as being asleep. However, when CCTV footage was reviewed by police, it revealed that a large number of these checks had not been completed.

The inquest heard how staff members had described the night in question as "chaotic" and "bedlam".

It heard that there was a "culture" at the hospital, which saw staff members "encouraged and expected" to complete records of observations - even when one had been missed.

An inquest jury recorded this fact in its conclusion - although it was acknowledged that this did not cause or contribute to Mr Harris' death.

The jury also concluded that staff with "inadequate training" were tasked with carrying out observations.

Eastern Daily Press: Cath Byford, deputy chief executive of NSFTCath Byford, deputy chief executive of NSFT (Image: NSFT)

Cath Byford, deputy chief executive of NSFT, said: "We would like to once again pass on our sincere condolences to Eliot's family and apologise for the distress his tragic loss has caused.

"The support we gave Eliot during his admission could and should have been better. We know that a poor culture had permeated good practice, in the absence of strong and stable leadership on the ward.

"We carried out an extensive internal investigation following Eliot's death and have made significant changes as a result.

"This includes rebuilding clinical leadership structures with experienced and substantive team members, strengthening staff training and care planning, improving the way we engage with patients' families and introducing new processes to make sure therapeutic observations are completed in a timely and consistent way.

"We have also held a series of mandatory safety workshops on the ward which all staff must attend."