Coroner Issues Prevention of Future Deaths Warning After Patient Strangled at East London Mental Health Unit

A coroner has formally warned that more patients could die at an east London mental health facility unless serious staffing and safety failures are urgently corrected, following the killing of a 34-year-old man by a fellow patient nearly three years ago.

Hugo Flint Cahan was strangled by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre in January 2023. The unit, run by East London NHS Foundation Trust (ELFT), provides care for acutely mentally ill men.

The warning comes in a Prevention of Future Deaths report sent by the senior coroner for east London, Graeme Irvine, to both the Trust and NHS England. Such reports are issued when a coroner believes action is needed to prevent similar fatalities in future, and they place a legal duty on recipients to respond.

The coroner's intervention follows a six-day inquest held in September, at which Irvine concluded that neglect had more than trivially contributed to Cahan's death. The inquest examined in detail the circumstances surrounding the attack and the conduct of staff on duty that night.

Among the most troubling findings were that staff on the ward were asleep while working and spent long periods on their mobile phones on the night Cahan died. The coroner's report sets out 14 separate areas of concern.

These include a failure to carry out timely and thorough observations of patients, followed by the falsification of records. The report states this was done "in the safe knowledge that staff on duty would not report or escalate the deception" — an allegation that points to a deeply embedded culture of non-reporting on the ward.

The document further details delays in beginning CPR after Cahan was discovered, which may have reduced any chance of saving his life. It also says staff misled police officers about what patients had been doing on the night of the incident, and that employees colluded with one another to take unauthorised breaks lasting two hours.

Torres-Pena was made subject to a hospital order with no time limit after pleading guilty to manslaughter by diminished responsibility in 2023. The order means he will remain detained in a secure setting until authorities deem it safe for him to be released.

The family's solicitor and Cahan's cousin, James Cahan, said the scale of dishonesty uncovered was highly unusual in a coronial investigation. He said the public is entitled to a clear explanation of how such conduct was permitted and what is being done to ensure it never recurs, describing findings of dishonesty on this scale as extraordinarily rare.

The coroner also voiced concern that many of the failings identified in this case had already been raised at a previous inquest he had conducted. His report notes that the findings are "strikingly similar" to those from an inquest before the same court in 2021.

That earlier case led to remedial measures being reported, but the coroner said those measures do not appear to have been implemented effectively by the Trust. The observation raises difficult questions about whether recommendations made after previous deaths were treated as a genuine priority or merely acknowledged and then set aside.

Separately, the coroner criticised NHS England for failing to make independently produced reports into patient safety at Trusts publicly available. The inquest heard that a report commissioned after Cahan's death had already identified some of the serious failings the coroner later investigated. Publishing such documents, the coroner's report implies, would allow scrutiny and help prevent lessons from being lost.

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

In a statement, Dr David Bridle, Chief Medical Officer for ELFT, apologised to Cahan's family for the failings 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.

Dr Bridle added that the Trust would ensure the learning from the coroner's findings informs its continuing work to strengthen patient safety and care. ELFT has previously described the failings identified as "wholly unacceptable" and said it has undertaken a significant programme of work to improve inpatient services.

Both ELFT and NHS England have until 19 November to formally respond to the Prevention of Future Deaths report. Their replies will be expected to set out what action has been taken or is planned in response to each of the 14 concerns raised by the coroner.

The case also highlights broader questions about oversight of NHS mental health inpatient services, where staffing levels, observation practices and reporting culture can determine whether vulnerable patients are kept safe. The coroner's warning makes clear that, in this instance, several safeguards failed simultaneously — and that others elsewhere may be failing in similar ways.