NHS Coroner Finds Staff Slept, Lied to Police After Patient Was Strangled on Mental Health Ward

A coroner has told NHS England that patients remain at risk of dying at an east London mental health unit where staff slept on the job, falsified safety records, and misled police after a man was strangled by a fellow patient.

Hugo Flint Cahan, 34, was killed by 22-year-old Rolando Torres-Pena in January 2023 at Newham Mental Health Centre, a ward run by East London NHS Foundation Trust (ELFT) for acutely mentally ill men, according to BBC News. Torres-Pena pleaded guilty that year to manslaughter by diminished responsibility and received a hospital order with no time limit.

A six-day inquest in September, led by senior coroner for east London Graeme Irvine, concluded that neglect more than trivially contributed to Flint Cahan's death, BBC News reported. The coroner has now issued a Prevention of Future Deaths report to the trust and NHS England laying out 14 separate concerns.

What the Coroner Found

Staff on the ward were found to have been asleep and on their phones for long stretches the night Flint Cahan died, according to BBC News. The report says workers failed to carry out "timely and thorough observations" of patients, then falsified records "in the safe knowledge that staff on duty would not report or escalate the deception."

The coroner also found critical delays in starting CPR once Flint Cahan was discovered, that staff misled police about what patients had been doing that night, and that workers colluded to take unauthorized two-hour breaks.

"Findings of dishonesty on this scale are extraordinarily rare in a coronial investigation," James Cahan, the family's solicitor and Hugo's cousin, told the BBC. "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."

Not the First Warning

The coroner flagged that this isn't new territory for the trust. He noted the findings were "strikingly similar" to a 2021 inquest he had conducted, and that "remedial measures reported in that case do not appear to have been implemented effectively by the trust," according to BBC News.

A coroner already told this trust what was broken four years earlier. The same breakdowns happened again, and a man died.

ELFT says the failings were "wholly unacceptable" and that it has launched a "significant programme of work" to improve inpatient services, according to BBC News. Dr. David Bridle, the trust's chief medical officer, apologized to Flint Cahan's family and said one staff member on duty that night faced consequences, though the specifics of any discipline or dismissals were not detailed in the reporting available.

The coroner also criticized NHS England for not publicly releasing independently produced patient safety reports. The inquest heard that a report commissioned after Flint Cahan's death had already identified some of the same failings the coroner later investigated. An NHS spokesperson told the BBC that "patient safety incident investigations should always be published, with any necessary redactions to protect patients' identities, while making sure the lessons and learning are clear." Whether it gets applied here, after the fact, is a separate question.

Part of a Pattern

This isn't an isolated coroner's warning to the NHS this fall. In a separate case out of County Durham, senior assistant coroner Crispin Oliver sent NHS England a Prevention of Future Deaths report in July after finding ambulance delays contributed to the death of Andrew Edward Watson, 32, according to Chronicle Live. Watson died in 2019, 67 minutes after calling 999 himself for a tonsil infection that blocked his airway. Oliver said he was "baffled" that a 999 call made by the patient himself, rather than a third party, generated a lower-priority ambulance response under the service's triage algorithm.

Two different coroners, two different NHS bodies, both flagging systemic risk rather than a one-off error.

A Harder Question Underneath

Separately, in the United States, the difficulty of predicting dangerousness in severely mentally ill patients has drawn renewed scrutiny following the case of Illinois mother Corie Walsh, who has been deemed too dangerous to return home. Northwestern psychiatrist Dr. Stephen Dinwiddie has argued publicly that psychosis and dangerousness are widely misunderstood, and that risk level in such patients can shift over time, according to Fox News. That's a different case with different facts, but it underscores a real clinical challenge: assessing who is dangerous, and when, is genuinely hard even when staff are doing their jobs properly. Critics of psychiatric institutions sometimes treat every bad outcome as a simple failure of will or effort. Clinicians like Dinwiddie push back on that, arguing some risk cannot be eliminated no matter how good the monitoring is.

That argument doesn't excuse what happened at Newham. The coroner's findings there aren't about the limits of psychiatric prediction. They're about staff allegedly asleep, lying to police, and fabricating paperwork on a ward meant to supervise acutely mentally ill men around the clock. NHS England has not said whether it will make the earlier, pre-inquest patient safety report public, and ELFT has not detailed what disciplinary action, if any, was taken against staff on duty that night. Those remain open questions as the trust responds to the coroner's 14 concerns.