Coroner Warns of Further Deaths After Newham Centre Killing

A man was unlawfully killed at Newham Mental Health Centre in January 2023, prompting a warning from a senior coroner that further deaths could occur. Hugo Flint Cahan, 34, was strangled by fellow patient Rolando Torres-Pena, 22, at the east London facility. Senior coroner for east London, Graeme Irvine, has submitted a Prevention of Future Deaths report to the East London NHS Foundation Trust and NHS England, detailing significant concerns about the care provided.

Neglect and Falsified Records Cited

The six-day inquest concluded that Mr Flint Cahan's death was unlawfully caused and contributed to by neglect. The coroner's report highlighted 14 concerns, including staff being asleep and using phones during their shifts, failure to conduct timely patient observations, and the falsification of records. One instance involved a staff member completing an observation log without verifying patient locations. The court heard that CPR was delayed, with one nurse stating it was too late to start and that they wished to preserve the crime scene. Staff were also found to have colluded to take unauthorised two-hour breaks.

Mr Flint Cahan had been a patient at the centre for six months, while Mr Torres-Pena had been admitted just five days prior. The coroner noted that many of the issues raised had also been identified in a previous inquest in 2021. The report stated that remedial measures from the earlier case did not appear to have been effectively implemented by the trust. Coroners have sent at least 29 Prevention of Future Deaths notices to the trust over the past 12 years.

Trust Responds to Findings

James Cahan, family solicitor and cousin to Mr Flint Cahan, described the findings of dishonesty on this scale as extraordinarily rare and stated the public deserves a clear explanation. An NHS spokesperson indicated that patient safety incident investigations should be published to ensure lessons are learned. Dr David Bridle, chief medical officer for the East London NHS Foundation Trust, apologised to Mr Flint Cahan’s family for the failings. He confirmed that one staff member on duty that night had been dismissed, and four others are currently under investigation by the trust. The trust and NHS England are required to respond to the coroner's report by 19 November.

Rolando Torres-Pena pleaded guilty at the Old Bailey to manslaughter by diminished responsibility in 2023 and was given a hospital order with no time limit.