A nurse at a private psychiatric hospital in Roehampton has been struck off after falsifying a patient’s medical records to hide a drug error.
Santa Mandera, a registered mental health nurse with 22 years on the register, was found to have left a high-risk patient unsupervised, given two other patients the wrong doses of medication, and then altered a record to cover up one of the mistakes. The Nursing and Midwifery Council, the profession’s regulator, ruled she was dishonest and struck her off in July.
The name of the hospital has been redacted in the final report [pdf].
The Care Quality Commission had rated the hospital Good only months before, upgrading it from Requires Improvement in September 2020. That rating was still current throughout the period covered by Mandera’s case.
On a night shift in March 2021, while working as nurse in charge, Mandera was responsible for one-to-one observation of a patient assessed as high risk, who had previously tried to smoke on the ward. The tribunal heard that staff treated this as a serious fire risk, given the hospital had experienced a fire caused by smoking not long before. Mandera left the patient unsupervised for around 20 minutes.
Four months later, over a night shift at the end of July, she gave one patient more than double their prescribed dose of Diazepam, and gave a second patient a dose of Olanzapine that had already been discontinued by a doctor. She then recorded giving that patient a second dose of the same drug at midnight. A tribunal panel found she had not actually given it, and that the false entry was a deliberate attempt to hide the earlier mistake.
A separate error, in August 2021, saw her copy one patient’s background notes into a different patient’s file. The panel accepted this was a genuine mistake rather than dishonesty, but still a serious lapse in record-keeping.
Resigned but then continued to work
The hospital’s own drugs audit picked up the discrepancy, and an internal investigation followed. Mandera denied the allegations when interviewed. She resigned in November 2021, still while the hospital held its Good rating, two months before its own disciplinary hearing concluded. She was referred to the NMC in January 2022.
It then took almost four years for the case to reach a hearing. Mandera continued working as a nurse until August 2025, the same month the tribunal hearing began; it did not reach a final decision until this July.
At the hearing, she disputed most of the charges, and suggested someone else may have signed the medication chart. The panel rejected this explanation as unsupported by any evidence, and found that CCTV footage contradicted her account of the observation failure.
She admitted that her conduct amounted to misconduct, which the panel took into account in her favour, and had completed training on record-keeping and accountability since leaving the hospital. But it found little evidence she had reflected on what went wrong or applied that training in practice, and concluded the case involved “a disregard for patient safety, professional accountability” rather than a lack of training.
The panel struck her off the register, the most serious sanction available, and imposed a further eighteen-month suspension to cover the period in which she could appeal.
The hospital has since changed hands. Under its new owner it was rated Requires Improvement in 2023, before being upgraded back to Good this year.
