Coroner Issues Prevention of Future Deaths Warning to East London NHS Trust After Patient Killed by Fellow Inpatient

A coroner has issued a formal warning that more deaths could occur at an east London mental health facility unless serious staffing failures are urgently corrected, following the killing of a patient by another man receiving care on the same ward.

Hugo Flint Cahan, 34, was strangled by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre in January 2023. The unit provides specialist care for men experiencing acute mental illness. Torres-Pena was subsequently handed a hospital order without a time limit after admitting manslaughter by diminished responsibility in 2023.

The warning comes in a Prevention of Future Deaths report sent by the senior coroner for east London, Graeme Irvine, to East London NHS Foundation Trust (ELFT) and NHS England. Such reports are issued when a coroner believes action is needed to prevent similar fatalities in the future, and recipients are legally required to respond.

The coroner's intervention follows a six-day inquest held in September, at which Irvine concluded that neglect had contributed to Cahan's death in more than a trivial way. The inquest painted a troubling picture of conditions on the ward during the night shift when the attack took place.

According to the coroner's report, staff on duty were found to have been asleep while working and spent extended periods on their phones. The document sets out 14 separate areas of concern, including a failure to conduct timely and thorough observations of patients.

Perhaps most disturbingly, the report states that records were then falsified, with staff doing so "in the safe knowledge that staff on duty would not report or escalate the deception". The coroner also found that workers colluded with one another to take unauthorised breaks lasting two hours at a time.

Further concerns include delays in beginning CPR after Cahan was discovered, and the fact that staff gave misleading information to police about what patients had been doing on the night of the incident. These findings suggest a culture in which basic standards of care and honesty broke down simultaneously.

The coroner noted that many of the same problems had already been raised at a previous inquest he conducted. "The findings in this inquest are strikingly similar to the findings of an inquest before this court in 2021," the report says, adding that remedial measures reported in that earlier case did not appear to have been effectively implemented by the trust.

That repetition has prompted particular alarm. The report describes the scale of dishonesty uncovered as extraordinarily rare in a coronial investigation, and calls for a clear public explanation of how such behaviour was allowed to occur and what will be done to prevent a recurrence.

James Cahan, the family's solicitor and Hugo's cousin, said the public is entitled to expect transparency. "Findings of dishonesty on this scale are extraordinarily rare in a coronial investigation," he said. "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."

The coroner also directed criticism at NHS England, accusing the body of failing to make independently produced patient safety reports about Trusts publicly available. The inquest heard that a report commissioned after Cahan's death had already identified some of the serious failings that the coroner later investigated.

An NHS spokesperson responded by saying that patient safety incident investigations should always be published, with any necessary redactions applied to protect patients' identities, while ensuring that the lessons and learning are made clear. The statement suggests a measure of agreement with the coroner's position on transparency.

ELFT has acknowledged the severity of the findings. Dr David Bridle, the Trust's Chief Medical Officer, apologised to Cahan's family for the failures in his care. He confirmed that one member of staff on duty on the night of the incident has been dismissed, while four others are now the subject of an internal Trust investigation.

"We will ensure the learning from the coroner's findings informs our continuing work to strengthen patient safety and care," Dr Bridle said. The Trust has previously described the failings identified as "wholly unacceptable" and said it has undertaken a significant programme of work aimed at improving its inpatient services.

Both ELFT and NHS England have until 19 November to formally respond to the coroner's report. Their replies will be expected to set out in detail what actions have been taken or are planned, and how the Trust intends to address the cultural and supervisory weaknesses the inquest exposed.

The case raises broader questions about oversight of acute mental health wards, where patients can be highly vulnerable and staffing pressures are often intense. The coroner's findings suggest that in this instance, the safeguards meant to protect patients failed at multiple levels, from frontline observation to management supervision and record-keeping integrity.

For Cahan's family, the report represents both a measure of accountability and a warning that the system has not yet demonstrated it can keep others safe. With a deadline now set for official responses, attention will turn to whether the promised improvements translate into meaningful change on the ward, or whether the pattern identified across two inquests will persist.