Coroner Warns of Further Deaths at East London Mental Health Unit After Patient’s Killing

A coroner has issued a formal warning to an east London mental health trust, stating that further fatalities may occur unless serious staff negligence and safety failings are addressed. The alert follows the death of Hugo Flint Cahan, 34, who was strangled by fellow patient Rolando Torres-Pena at the Newham Mental Health Centre in January 2023.

Graeme Irvine, the senior coroner for east London, concluded after a six-day inquest in September that neglect had more than trivially contributed to Cahan’s death. The resulting Prevention of Future Deaths report outlines 14 distinct concerns regarding patient care and staff conduct.

The investigation revealed that ward staff were asleep on duty and using their phones for extended periods on the night of the incident. When Cahan was attacked, there were significant delays in the commencement of CPR. Furthermore, the report highlights that staff falsified patient observation records, knowing that colleagues would not report the deception, and colluded to take unauthorized two-hour breaks.

Coroner Irvine also noted that staff members misled police investigators about the patients’ activities that night. He criticized the lack of accountability, noting that many of the failings identified mirrored those found in a previous inquest in 2021, suggesting that remedial measures from that case were not effectively implemented.

“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,” said James Cahan, Hugo’s cousin and family solicitor.

Torres-Pena, 22, was diagnosed with a mental disorder and received a hospital order with no time limit after pleading guilty to manslaughter by diminished responsibility in 2023.

The coroner also directed criticism at NHS England for failing to make independently produced patient safety reports publicly available. While an NHS spokesperson acknowledged that such investigations should generally be published with appropriate redactions, the current policy limits transparency.

Dr. David Bridle, Chief Medical Officer for the East London NHS Foundation Trust (ELFT), apologized to the Cahan family for the inadequate care provided. He confirmed that one staff member was dismissed following the incident, while four others are currently under investigation.

“We will ensure the learning from the coroner’s findings informs our continuing work to strengthen patient safety and care,” Dr. Bridle stated. ELFT and NHS England have until November 19 to respond to the coroner’s report.