ELFT and NHS England must answer coroner's 14 concerns over 2023 Newham death

The senior coroner for east London, Graeme Irvine, issued a Prevention of Future Deaths report that warns further fatalities could occur at Newham Mental Health Centre unless the identified failings are corrected, as reported by the BBC. The report lists 14 specific concerns and sets a deadline of 19 November for East London NHS Foundation Trust (ELFT) and NHS England to reply. Hugo Flint Cahan, 34, was strangled by 22‑year‑old patient Rolando Torres‑Pena in January 2023 while both men were under the Trust’s care.

Background to the incident

The incident occurred on a ward for acutely mentally ill men. On the night of the killing, staff were found sleeping and using mobile phones for extended periods, according to the BBC. The coroner’s inquest, held over six days in September, concluded that neglect played a more than trivial role in Cahan’s death. The report also notes that staff delayed the start of CPR and provided false information to police about the patients’ activities.

Coroner’s findings

Among the 14 concerns are failures to carry out timely and thorough observations, falsifying records with the expectation that on‑duty staff would not raise alarms, and two‑hour unauthorised breaks taken by staff members. The coroner highlighted that similar failings had been raised in a previous 2021 inquest but remained unaddressed. The report states that such scale of dishonesty is extraordinarily rare in coronial investigations.

Trust’s response

ELFT described the identified failings as wholly unacceptable and said it has launched a significant programme of work to improve inpatient services, as reported by the BBC. Dr David Bridle, chief medical officer for ELFT, apologised to Cahan’s family and confirmed that one staff member on duty that night has been dismissed while four others are under investigation. He added that the Trust will ensure lessons from the coroner’s findings shape ongoing patient‑safety initiatives.

NHS England was also criticised for not publishing independently produced patient‑safety reports. An NHS spokesperson said such investigations should always be published, with necessary redactions, to make lessons clear. The Trust and NHS England must now prepare formal responses by the 19 November deadline, after which the coroner may consider further action if the concerns are not adequately addressed.