NURSES and carers at Chalkdown House knew Daniel Beswick was a suicide risk.

The 31-year-old was at the Dorcan brain injury rehabilitation clinic after an earlier attempt at taking his own his life had left him with brain damage.

In September 2015 he was placed on constant observations. That stopped the day before he died – after constant complaints from the vulnerable patient.

The door to his private room was locked and staff were meant to check on him at least every 15 minutes.

On the night of September 17, however, the unit was short-staffed. A number of patients were on one-to-one observations, with carers having to keep them under constant watch. Two other staff members had had to go to hospital with another patient. And Samuel Haward, an agency nurse who usually worked at HMP Broadmoor, had let bosses know the day before that he was going to be late for his shift.

At 8.45pm, agency support worker Nthabiseng Bodiba got a call asking her to come in to work.

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Chalkdown House, Dorcan

Petua Nugent, another agency worker, was the only registered nurse on duty when the night shift started at 9pm.

She knew Daniel was a suicide risk and checked up on him after 9pm as she did her first medication rounds.

Ms Nugent said she was getting increasingly concerned about where Sam Haward had got to. She was in the medication room, sorting out the second lot of prescriptions, when her colleague walked into the staff office.

“I asked him what was the matter because he was walking around. He was holding his head. I asked him ‘what’s the problem? What’s the matter?’ He didn’t say anything. I asked him again, ‘what is it? What’s the problem?’ Then he said a patient has died,” she said.

It was only when she heard him speaking to the 999 operator that she realised it was Daniel.

The police call handler spoke to three staff members: Sam Haward, Petua Nugent and Nthabiseng Bodiba.

“A patient hanged himself,” Haward tells the operator. How long has the person been there, do you know? “No, for me I’ve just arrived on duty.”

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Nthabiseng Bodiba

When was he last seen? the operator asked. Haward is heard repeating the question before Ms Nugent is handed the phone. “About 9.20pm.”

Has anybody attempted to resuscitate him? The answer: no. The question was repeated when Bodiba was handed the phone and the same answer given.

The operator asked if there was any reason why resuscitation had not been attempted. “They’re doing it now,” Bodiba said.

Nugent was performing CPR as paramedics arrived at 10.10pm – around 10 minutes after the call was made.

Daniel was declared dead at 10.50pm.

It was what happened after that that saw all three health professionals hauled before Swindon Crown Court almost five years later.

In the wake of Daniel’s death all three had spoken to bosses and made statements to the police about the events of that night. The accounts tallied: Bodbiba had found Daniel’s body, pulled an alarm and gone to get help. Haward – signing in at reception – answered the call for help, cut Daniel down and began chest compressions. Bodiba fetched Petua Nugent, who took over CPR as Haward went to call 999. After handing the phone to other staff members the nurse went to wait for the ambulance then returned to Daniel’s room after Bodiba took over at the front of the building.

Adrian Bray, the detective tasked with investigating the death, was suspicious. The 999 call didn’t fit.

Daniel’s body had been found at around 9.45pm. The call was made at 9.57pm. If Haward had been doing CPR for the best part of 10 minutes why wasn’t he out of breath? Petua Nugent took the phone from Haward – so who was with Daniel then? And why did they all tell the police operator that no resuscitation had been carried out?

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Samuel Haward outside Swindon Crown Court

All three were invited to interview early the next year. At that stage they were under investigation for manslaughter and perverting the course of justice.

Haward and Bodiba stuck to their accounts. But just hours after being played the 999 recording in her first interview in February 2016, Petua Nugent called her solicitor in a panic. She admitted she’d lied.

On the witness stand at Swindon Crown Court she claimed to have come under pressure from her colleagues to keep to her story, with Haward allegedly meeting her at a London branch of Harvester one night.

Ms Nugent told jurors of her lie: “It was not right. It was stupid. I did not think through it properly. I don’t know – it was pressure. It was a terrible thing I should not have done.”

She turned Queen’s evidence, cutting a deal with the Crown Prosecution Service agreeing to testify against her colleagues at their trial in return for a lighter sentence.

Throughout the trial, the two in the dock stuck to their original account. “I’m not lying,” Bodiba told jurors in a cracking voice. “I have no reason to lie.” Her barrister, Len Furlong, went further and accused Petua Nugent of lying on the stand and pointed to a comment recorded in the 999 call where she turns to Bodiba and asks “what time did you call me?”

“It’s glaringly obvious she left Daniel. She abandoned Daniel. She created this gap in care for Daniel,” he said.

Mr Furlong pointed to the fact that English was South African native Bodiba’s fourth or fifth language. “It was said they are not on trial for panicking. It’s exactly why they’re on trial, because they haven’t said the right things at the right time.”

Put on the stand Haward said he was just a responder who had done the best he could at the time.

Prosecutor Nicholas Tucker asked jurors why the defendants would have lied: “Only they can say for sure but on behalf of the prosecution I suggest they did so in order to cover up the fact that neither of them had – as they should have – promptly administered CPR to Daniel when they should have done.”

The Swindon jury took around four hours to unanimously find both defendants guilty of perverting the course of justice.

Bodiba, of Tyndale Gardens, Park North, and Haward, of Tavistock Road, Reading, will be sentenced at Taunton Crown Court on March 31.

Why did Chalkdown House close?

A falling number of patients and an inability to recruit staff resulted in the closure of Chalkdown House in 2017 – just four years after it opened.

The Brain Injury Rehabilitation Trust, which ran the facility, said it was concerned it wouldn’t be able to sustain quality care.

In a statement, the charity said: “Due to pressures and changes within the NHS, admissions have fallen and the centre has always struggled to recruit clinical and managerial staff, given the high demand for these posts from other local employers.”

Interim director of the Brain Injury Rehabilitation Trust Penny Blackmore added: “This has been a very difficult decision for the Trust to take and one which we have made with great reluctance.

“Despite everyone’s best efforts, we have been unable to generate the number of admissions or to recruit the clinical and managerial staff required to sustain the quality of the service for the longer term.

“There has been increased pressure on the NHS which funds placements at the service, along with changes in the way brain injury rehabilitation is commissioned.

She added: “The local employment market means there is significant demand for psychologists and therapists, and we have found it very difficult to recruit and retain those staff.

“This is a sensitive time for everyone involved - for the people at the centre, their families and for the affected staff but we genuinely feel that this is the right decision. The Trust will provide all the advice and support we can over the coming months.”

The unit had space for 20 patients. Swindon Crown Court heard that the unit had been short-staffed. All four of the nurses or support workers who gave evidence at the trial had been agency staff members.