A senior coroner has warned an East London NHS trust that further deaths may occur at its mental health unit unless serious failings are addressed, after a patient was killed on a ward where staff were found to have slept on duty and falsified observation records.
Hugo Flint Cahan, 34, was strangled by a fellow patient, Rolando Torres-Pena, 22, at Newham Mental Health Centre in January 2023. The centre provides care for acutely mentally ill men. Following a six-day inquest in September, Graeme Irvine, the senior coroner for east London, concluded that neglect had more than trivially contributed to Mr Flint Cahan’s death.
Fourteen concerns set out in coroner’s report
In a Prevention of Future Deaths report sent to East London NHS Foundation Trust (ELFT) and NHS England, the coroner set out 14 concerns. The report found staff had failed to carry out “timely and thorough observations” of patients, then falsified records “in the safe knowledge that staff on duty would not report or escalate the deception”.
The report also said there were delays in starting CPR after Mr Flint Cahan was discovered, that staff misled police about what patients had been doing on the night of the incident, and that staff colluded with each other to take two-hour unauthorised breaks. On the night of his death, staff on the ward were found to have been asleep on the job and on their phones for long periods.
The coroner said the findings were “strikingly similar” to those of an inquest he had conducted in 2021, adding that remedial measures reported in that case “do not appear to have been implemented effectively by the trust”. The warning comes amid wider pressure on mental health services in the capital — concern was recently raised about cuts at East London’s mental health trust as demand soars.
The coroner also criticised NHS England for not making independently produced reports into patient safety at trusts publicly available. The inquest heard that a report commissioned after Mr Flint Cahan’s death had identified some of the serious failings the coroner investigated.
James Cahan, the family’s solicitor and Hugo’s cousin, said: “Findings of dishonesty on this scale are extraordinarily rare in a coronial investigation. The public are entitled to expect a clear explanation of how this was allowed to happen and what is being done to ensure it never happens again.”
Trust apologises and says failings were “wholly unacceptable”
ELFT described the failings identified as “wholly unacceptable” and said it had undertaken a “significant programme of work” to improve inpatient services. Dr David Bridle, the trust’s chief medical officer, apologised to Mr Flint Cahan’s family. He said one member of staff on duty on the night had been sacked, while four others were now under investigation by the trust.
“We will ensure the learning from the coroner’s findings informs our continuing work to strengthen patient safety and care,” Dr Bridle said. An NHS spokesperson said “patient safety incident investigations should always be published, with any necessary redactions to protect patients’ identities, while making sure the lessons and learning are clear”.
Torres-Pena was given a hospital order with no time limit after pleading guilty to manslaughter by diminished responsibility in 2023. ELFT and NHS England have until 19 November to respond to the coroner’s report.
East London hospitals have faced repeated safety scrutiny in recent months — Homerton Hospital recently suspended home births while bosses ordered a safety review.
What is a Prevention of Future Deaths report?
When an inquest reveals a concern that deaths could occur in similar circumstances in future, the coroner has a legal duty under the Coroners and Justice Act 2009 to issue a report to the organisation best placed to take action. The organisation must respond within 56 days, setting out what it has done or plans to do — or explaining why no action is proposed. Both the reports and the responses are published by the Chief Coroner, making them one of the few public windows into how safety lessons are handled after a death.
How families can raise concerns about NHS care
Families who are worried about a relative’s care can start with the trust’s Patient Advice and Liaison Service (PALS), which offers confidential advice and help resolving issues informally. If that does not resolve the matter, they can make a formal written complaint to the trust, which must acknowledge and investigate it under the NHS complaints procedure.
Anyone who remains dissatisfied can escalate their complaint to the Parliamentary and Health Service Ombudsman, the final stage of the NHS complaints process. Concerns about the quality or safety of services can also be reported directly to the Care Quality Commission, the independent regulator of health and care in England. Separately, the NHS has expanded Martha’s Rule, which gives patients and families the right to request a rapid second opinion when they feel concerns about deterioration are not being heard.
