Brief
Coroner warns of further deaths after patient killing at East London mental health centre
The senior coroner for east London says staff failures at Newham Mental Health Centre led to the unlawful killing of Hugo Flint Cahan in January 2023.
By Felo News Desk · Published
A senior coroner for east London has issued a Prevention of Future Deaths report warning that further fatalities could occur at Newham Mental Health Centre after a patient was killed by another patient in January 2023.
What happened
In January 2023, 34‑year‑old Hugo Flint Cahan was strangled by 22‑year‑old Rolando Torres‑Pena on a ward for acutely mentally ill men. The inquest, which lasted six days, concluded that Flint Cahan was unlawfully killed and that neglect contributed to his death.
What the report adds
The coroner’s report, submitted to the East London NHS Foundation Trust and NHS England, lists 14 concerns, including staff sleeping on the job, long periods on phones, failure to carry out timely observations, and falsification of records. It also notes delays in starting CPR and that police were misled about the patients’ activities. The report cites a previous 2021 inquest with similar findings that have not been fully addressed.
What was said
Graeme Irvine, senior coroner, said the findings were “strikingly similar” to the 2021 inquest and recommended that staff be referred to their regulator and that the Met Police review its investigation. James Cahan, the victim’s cousin and family solicitor, told the BBC that “findings of dishonesty on this scale are extraordinarily rare in a coronial investigation.” An NHS spokesperson said a patient‑safety incident investigation was underway.
How it came about
The inquest followed a 2021 coroner’s inquiry that also highlighted systemic failings at the Trust. Over the past 12 years, local coroners have issued at least 29 Prevention of Future Deaths notices to the Trust, indicating a pattern of repeated concerns about patient safety.
Key facts
- Hugo Flint Cahan was strangled by another patient at Newham Mental Health Centre in January 2023. (standard.co.uk)
- The senior coroner concluded Flint Cahan was unlawfully killed and cited neglect as a contributing factor. (standard.co.uk)
- The coroner’s report listed 14 concerns, including staff sleeping, phone use, delayed CPR, and falsified records. (standard.co.uk)
- The report recommends staff referral to their regulator and a Met Police review of the investigation. (standard.co.uk)
- Over 12 years, at least 29 Prevention of Future Deaths notices have been sent to the Trust. (standard.co.uk)
Timeline
- 2023-01-XX — Hugo Flint Cahan killed at Newham Mental Health Centre
- 2021-XX-XX — Previous inquest with similar findings
- 2026-10-02 — Coroner’s report issued and reported by standard.co.uk
Sources
- [1] standard.co.uk — originally reported as “Killing of man at east London mental health centre sparks warning from coroner”
