Coroner warns Newham mental health unit of further fatal risks unless reforms made

During a six-day inquest, senior coroner Graeme Irvine concluded that neglect played a significant role in the death of Hugo Flint Cahan, who was strangled by 22-year-old patient Rolando Torres-Pena at Newham Mental Health Centre in January 2023. The coroner’s Prevention of Future Deaths report lists fourteen concerns, including staff sleeping on duty, prolonged phone use, falsified observations, delayed CPR and misleading police statements.

East London NHS Foundation Trust called the failings "wholly unacceptable" and has launched a "significant programme of work" to overhaul inpatient services, while one staff member has been dismissed and four are under investigation. The report also censured NHS England for not making independent patient-safety investigations publicly available. Both the Trust and NHS England must respond by 19 November.