Overview

• The support worker used a stolen identity and minimal agency training, failed to maintain the required one-to-one observation and fled to Ghana after his shift ended
• Staff testified that at least half of the Thames ward team were absent on February 12, forcing nurses to cover breaks and preventing a formal induction for the new worker
• Senior clinicians filed a risk management alert over chronic short-staffing, but hospital management did not increase staffing levels before the fatal lapse
• Evidence highlighted two unfavourable Care Quality Commission reports prior to the hospital’s closure, underscoring longstanding regulatory and oversight gaps in secure adolescent care
• Thames Valley Police have established the worker’s true identity but lack grounds for extradition, and the inquest is continuing at Buckinghamshire Coroner’s Court