Coroner warns of risk of future deaths at mental health unit where patient was killed

A mental health trust in east London has been formally warned that further deaths could occur unless serious staffing and record-keeping failings are fixed. The warning comes in a Prevention of Future Deaths report from the senior coroner for east London, Graeme Irvine, following the killing of Hugo Flint-Cahan, 34, at Newham Mental Health Centre in January 2023.

What happened at the unit

Cahan was strangled by 22-year-old Rolando Torres-Pena at the centre, which provides care for acutely mentally ill men. Torres-Pena pleaded guilty to manslaughter by diminished responsibility in 2023 and was given a hospital order with no time limit.

A six-day inquest in September concluded that neglect had more than trivially contributed to Cahan’s death. The coroner has now sent the report to the trust and to NHS England.

Staff asleep and records falsified

The report highlights 14 concerns. On the night of Cahan’s death, staff on the ward were found to have been asleep on the job and on their phones for long periods. The coroner says observations of patients were not carried out in a timely or thorough way, and that records were then falsified in the safe knowledge that colleagues on duty would not report or escalate the deception.

There were also delays in starting CPR when Cahan was discovered. Staff are said to have misled police about what the two patients had been doing that night, and to have colluded with each other in taking two-hour unauthorised breaks.

Concerns that had been raised before

One of the most damaging elements of the report is that many of the failings were not new. The coroner said the findings in this inquest were “strikingly similar” to those of an inquest he conducted in 2021, adding that remedial measures reported in that case “do not appear to have been implemented effectively by the trust”.

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East London NHS Foundation Trust said the failings identified were “wholly unacceptable” and that it had undertaken a “significant programme of work” to improve inpatient services. Dr David Bridle, the trust’s chief medical officer, apologised to Cahan’s family for the failings in his care. One member of staff on duty that night has been sacked and four others are under investigation.

Transparency questioned

The coroner also criticised NHS England for not making independently produced patient safety reports at trusts publicly available. The inquest heard that a report commissioned after Cahan’s death had already identified some of the failings the coroner went on to catalogue. An NHS spokesperson said such investigations should always be published with any necessary redactions to protect patients’ identities.

James Cahan, the family solicitor and Hugo’s cousin, said findings of dishonesty on this scale are extraordinarily rare in a coronial investigation, and that the public are entitled to an explanation of how it was allowed to happen.

Why it matters

Acute mental health wards hold some of the most vulnerable people in the NHS, many of them in crisis and at risk of harming themselves or others. The report describes a ward where observation was treated as a box to be ticked, breaches went unrecorded, and staff covered for one another. That combination is a patient safety failure of a particular kind, because the safeguards that are supposed to catch a deteriorating situation had themselves been quietly removed.

The repetition of findings first raised in 2021 is arguably the more serious element. It suggests the trust’s response to a previous inquest did not reach the ward floor.

What happens next

East London NHS Foundation Trust and NHS England have until 19 November to respond to the coroner with details of what they will do to address the concerns. The four staff members under investigation face disciplinary action, and the trust has committed to ensuring the learning from the coroner’s findings is reflected in its ongoing patient safety work.