A mental health trust in east London, where a man was killed by a fellow patient, has been warned further deaths may occur unless staff issues are addressed.
Hugo Flint Cahan, 34, was strangled by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre, which provides care for acutely mentally ill men, in January 2023.
The coroner has sent a report to the Trust and NHS England raising serious concerns about the care the two men received.
It follows a six-day inquest in September during which the senior coroner for east London, Graeme Irvine, concluded that neglect had more than trivially contributed to Cahan's death.
On the night of Cahan's death, staff on the ward were found to have been asleep on the job and on their phones for long periods.
East London NHS Foundation Trust (ELFT) says the failings identified were "wholly unacceptable" and that it has undertaken a "significant programme of work" to improve inpatient services.
The coroner's Prevention of Future Deaths report highlights 14 concerns. These include failing to carry out "timely and thorough observations" of patients, then falsifying records "in the safe knowledge that staff on duty would not report or escalate the deception".
The document also says there were delays in starting CPR on Cahan when he was discovered, that staff misled the police as to what the patients had been doing on the night of the incident, and that staff colluded with each other to take two-hour unauthorised breaks.
Source: BBC News, 2 October 2026
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