A mental health facility operated by East London NHS Foundation Trust has received a warning from the coroner following the death of a patient at Newham Mental Health Centre. Hugo Flint Cahan, age 34, was fatally strangled by another patient, Rolando Torres-Pena, age 22, in January 2023. The coroner conducted a six-day inquest in September and determined that neglect had more than trivially contributed to Flint Cahan’s death.
The Prevention of Future Deaths report issued by the coroner identifies 14 specific concerns regarding operations at the facility. These include failures to perform timely and thorough patient observations, falsification of records, delays in initiating CPR when Flint Cahan was discovered, and staff providing misleading information to police about patient activities on the night of the incident. The report also notes that staff engaged in unauthorized two-hour breaks while colluding with one another.
The coroner expressed particular concern that similar findings had emerged in a previous inquest conducted in 2021, suggesting that remedial measures from that investigation had not been effectively implemented by the trust. The report further criticized NHS England for not making independent patient safety reports publicly available, stating that findings of dishonesty at this scale are extraordinarily rare in coronial investigations.
In response, East London NHS Foundation Trust acknowledged the failings as wholly unacceptable and stated it has undertaken a significant program of work to improve inpatient services. The organization reported that one staff member has been terminated while four others remain under investigation. Both ELFT and NHS England have until 19 November to respond to the coroner’s report.
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