Coroner warns of risk of future deaths at mental health unit where patient was killed — SkimNews
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- Hugo Flint Cahan, 34, was strangled by fellow patient Rolando Torres-Pena, 22, at Newham Mental Health Centre in January 2023; Torres-Pena pleaded guilty to manslaughter by diminished responsibility and received a hospital order with no time limit.
- Senior coroner Graeme Irvine concluded neglect more than trivially contributed to Cahan's death after a six-day inquest, issuing a Prevention of Future Deaths report listing 14 concerns.
- Irvine found staff asleep on the job and on phones for long periods, falsifying patient observation records, delaying CPR, misleading police about what happened on the ward, and colluding to take two-hour unauthorised breaks.
- The coroner stated the findings were "strikingly similar" to a 2021 inquest before the same court, writing that remedial measures "do not appear to have been implemented effectively" by East London NHS Foundation Trust (ELFT).
- ELFT Chief Medical Officer Dr David Bridle apologised to Cahan's family, confirming one staff member on duty that night was sacked and four others are under investigation by the Trust.
- NHS England was separately criticised by the coroner for not making independently produced patient safety reports publicly available; both ELFT and NHS England have until 19 November to respond.
Why it matters: This is the second time the same coroner has flagged near-identical failings at ELFT — the 2021 inquest raised concerns that remedial measures "do not appear to have been implemented effectively," meaning the trust had years to fix systemic problems and didn't. With one staff member sacked, four under investigation, and NHS England itself criticised for opacity around patient safety reports, the structural accountability gap at the trust remains unresolved ahead of the 19 November deadline.
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