The senior coroner has warned that further deaths could occur at Newham Mental Health Centre unless urgent safety and staffing failings are addressed. Hugo Flint Cahan, 34, was strangled in January 2023; a six-day inquest found neglect had 'more than trivially' contributed to his death and listed 14 concerns, including staff sleeping on duty, falsified observation records and delays to CPR. ELFT apologised, dismissed one staff member and is investigating others; the trust and NHS England must respond to the coroner by 19 November.
Coroner Warns 'Further Deaths Possible' at Newham Mental Health Centre After Patient Was Killed
Hugo Flint-Cahan, 34, was fatally attacked by Rolando Torres-Pena, 22, at a mental health trust in east London [FAMILY HANDOUT]
The senior coroner for east London has issued a stark warning that further deaths could occur at Newham Mental Health Centre unless urgent staffing and safety failings are addressed. The warning follows the January 2023 killing of 34-year-old Hugo Flint Cahan, who was strangled by 22-year-old Rolando Torres-Pena while both men were inpatients at the unit.
Inquest Findings
After a six-day inquest in September, Coroner Graeme Irvine concluded that neglect had 'more than trivially' contributed to Cahan's death. He has published a Prevention of Future Deaths report sent to East London NHS Foundation Trust (ELFT) and NHS England that lists 14 specific concerns about the quality of care and the conduct of staff on the ward.
Key Failings Identified
The report highlights multiple serious failings, including:
- Staff being asleep while on duty and spending long periods on personal phones on the night of the killing.
- Failure to carry out 'timely and thorough observations' of patients and subsequent falsification of observation records.
- Delays in starting cardiopulmonary resuscitation (CPR) when Cahan was discovered.
- Allegations that staff misled police about patients' activities the night of the incident.
- Evidence that staff colluded to take unauthorised two‑hour breaks.
'The findings in this inquest are strikingly similar to the findings of an inquest before this court in 2021,' the coroner wrote, noting that previously reported remedial measures do not appear to have been implemented effectively by the trust.
Legal Outcome and Trust Response
Torres-Pena pleaded guilty to manslaughter by diminished responsibility in 2023 and was given a hospital order with no time limit. ELFT has apologised to Cahan's family. In a statement, Dr David Bridle, Chief Medical Officer for ELFT, said one member of staff on duty the night of the incident has been dismissed and four others are under investigation. He added that the trust is undertaking a significant programme of work to improve inpatient safety.
'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, the family solicitor and Hugo's cousin.
Concerns About Transparency
The coroner also criticised NHS England for not publishing independently produced patient safety reports from trusts. An NHS spokesperson said patient safety incident investigations should be published with necessary redactions to protect identities while making lessons and learning clear.
ELFT and NHS England have been given until 19 November to respond to the coroner's report.
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