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

A senior coroner has warned that further deaths may occur at an east London mental health unit unless staff issues are addressed, following an inquest into the January 2023 death of Hugo Flint Cahan, 34, who was strangled by fellow patient Rolando Torres-Pena, 22, at Newham Mental Health Centre.

Coroner Graeme Irvine concluded that neglect had more than trivially contributed to Flint Cahan's death. His Prevention of Future Deaths report highlights 14 concerns at the facility, which provides care for acutely mentally ill men.

The coroner found staff were asleep on the job and on their phones for extended periods on the night of the killing. The report identifies failures in timely patient observations, falsified records, delayed CPR when Flint Cahan was discovered, staff misleading police about patient activities, and staff taking unauthorised two-hour breaks while colluding with each other. The coroner states that findings of dishonesty "on this scale are extraordinarily rare in a coronial investigation."

James Cahan, Hugo's cousin and family solicitor, called for "a clear explanation of how this was allowed to happen and what is being done to ensure it never happens again."

The coroner raised particular concern that similar findings had emerged at a previous inquest he conducted in 2021. "Remedial measures reported in that case do not appear to have been implemented effectively by the trust," his report states.

The coroner also criticised NHS England for not making independently produced patient safety reports at trusts publicly available. An NHS spokesperson acknowledged that "patient safety incident investigations should always be published, with any necessary redactions to protect patients' identities."

East London NHS Foundation Trust (ELFT) said the identified failings were "wholly unacceptable" and that it has undertaken a "significant programme of work" to improve inpatient services. Dr David Bridle, Chief Medical Officer for ELFT, apologised to Flint Cahan's family. One member of staff has been dismissed, and four others are under investigation by the trust.

Torres-Pena received a hospital order with no time limit after pleading guilty to manslaughter by diminished responsibility in 2023.

Both ELFT and NHS England have until 19 November to respond to the coroner's report.