A mental health trust in east London has received a warning from a coroner that further deaths may occur if staff issues are not addressed. This follows an inquest into the death of Hugo Flint-Cahan, who was killed by fellow patient Rolando Torres-Pena at Newham Mental Health Centre in January 2023.
The senior coroner for east London, Graeme Irvine, concluded that neglect had more than trivially contributed to Mr Cahan's death. The inquest heard that on the night of the incident, staff on the ward were found to have been asleep or on their phones for extended periods.
The coroner's Prevention of Future Deaths report outlines 14 concerns, including failures in patient observation and the falsification of records. It also noted delays in starting CPR for Mr Cahan and that staff misled police and colluded for unauthorised breaks. The report highlighted that similar failings had been raised in a previous inquest in 2021, suggesting remedial measures were not effectively implemented.
East London NHS Foundation Trust (ELFT) stated that the identified failings were "wholly unacceptable" and that it has initiated a "significant programme of work" to improve inpatient services. Dr David Bridle, Chief Medical Officer for ELFT, apologised to Mr Cahan's family, confirming one staff member has been dismissed and four others are under investigation.
The coroner also criticised NHS England for not making independently produced reports on patient safety at Trusts publicly available. An NHS spokesperson stated that patient safety incident investigations should always be published, with necessary redactions.