Damning CCTV from inside the unit was described minute by minute in court.
It showed Cerys going into the ward garden at 14:42. The observation record, which says at 14:45 she was in her bedspace, was described by the coroner as “not accurate”.
At 14:54, Cerys walked into another toilet on the ward and closed the door.
Yet Mr Rafiq told the coroner he remembered seeing Cerys at 14:57. He wrote in the observation notes that he had seen her at 15:00 “along the corridor, looking flat-faced”. He then went on a break. In reality, Cerys was still in the toilet.
The coroner told Mr Rafiq that his recollections were wrong, and that he had “falsified” the observation records. Mr Rafiq responded: “I’m afraid so”.
Mr Rafiq said other staff had shown him how to record observations every 15 minutes, even if he hadn’t done them. “That’s how they did it and that’s how I did it”, he told the court.
A new support worker took over the observations at 15:00. There was no verbal handover and, according to Mr Rafiq’s notes, Cerys had just been seen.
The CCTV shows the new support worker checking on other patients. At 15:15 she looked for Cerys.
She could be seen becoming increasingly desperate as she searched the communal areas and ran along the corridor.
At 15:19, she tried the door to the toilet, using a master key to unlock it. She found Cerys inside and immediately raised the alarm.
By that point, 25 minutes had passed since Cerys went into the toilet. She died in hospital on 18 May, five days later.
The coroner said there was a gross failure by Ms Talib to provide “basic medical attention to a person in a dependent position”.
He said it was not clear what Cerys’s intention had been. In a narrative conclusion, he recorded that neglect had contributed to her death.