Coroner warns of future deaths at east London mental health unit after patient killed

The senior coroner for east London, Graeme Irvine, has sent a Prevention of Future Deaths report to East London NHS Foundation Trust (ELFT) and NHS England, warning that further deaths may occur unless staff issues are addressed. 1 2 Hugo Flint Cahan, 34, was strangled by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre, which cares for acutely mentally ill men, in January 2023. 1 2 Flint Cahan had been a patient for six months, while Torres-Pena had arrived on the ward five days earlier, according to the Evening Standard. 2

Torres-Pena pleaded guilty to manslaughter by diminished responsibility in 2023 and was given a hospital order with no time limit. 1 2 The report follows a six-day inquest in September; the BBC says the coroner concluded that neglect had more than trivially contributed to the death, while the Standard says he concluded Flint Cahan was unlawfully killed, with neglect contributing. 1 2 Staff on the ward were found to have been asleep and on their phones for long periods on the night of the death, and the court heard staff discovered the victim almost two hours after he is believed to have been attacked. 1 2

The report lists 14 concerns, including failure to carry out "timely and thorough observations" and falsified records "in the safe knowledge that staff on duty would not report or escalate the deception". 1 2 It also cites delays in starting CPR, staff misleading police about what patients were doing that night, and staff colluding to take two-hour unauthorised breaks; the Standard adds that one nurse said he thought it was too late for CPR and wanted to preserve the crime scene. 1 2 The Standard reports that the coroner recommended staff be referred to their regulator and that the Met Police review their investigation. 2

The coroner said many failings echoed a 2021 inquest before the same court and that remedial measures from that case "do not appear to have been implemented effectively by the trust"; the Standard adds that local coroners have sent at least 29 such notices to the Trust over 12 years. 1 2 The coroner also criticised NHS England for not publishing independently produced patient safety reports; the inquest heard a report commissioned after the death had identified some of the failings. An NHS spokesperson said such investigations should always be published, with redactions to protect patients' identities. 1 The family's solicitor and Flint Cahan's cousin, James Cahan, said findings of dishonesty on this scale are "extraordinarily rare" and that the public is entitled to a clear explanation. 1

ELFT called the failings "wholly unacceptable" and said it has undertaken a "significant programme of work" on inpatient services. Chief Medical Officer Dr David Bridle apologised to the family, said one member of staff on duty has been sacked and four others are under investigation. 1 2 ELFT and NHS England have until 19 November to respond. 1 2