Staff falsified records, slept and were on their phones on the night one patient was killed by another on an NHS mental health unit in east London, an inquest has heard.
Hugo Flint-Cahan, 34, was being treated at Newham Mental Health Centre (NMHC), run by the East London NHS Trust (ELFT), when he was fatally attacked by 22-year-old Rolando Torres-Pena.
Hugo's family say they have been shocked by the "dangerous" failures in his care.
The Trust says it has undertaken a significant programme of work to "improve our inpatient culture, behaviours and practice".
In a narrative conclusion, the coroner found Hugo was unlawfully killed which was contributed to by neglect, recommended four members of staff be referred to their regulator and that the Metropolitan police review their investigation into what happened that night.
Hugo, who had been a patient at the NHMC for six months, was strangled in the early hours of 3 January 2023 by Torres-Pena who had arrived on the ward five days earlier.
A coroner criticised repeated failures by the Trust in a number of patient deaths - not just Hugo's.
Graeme Irvine, the Senior Coroner for East London, said it was like "ground hog day" as he heard evidence of "the same" errors, "over and over again," including the falsification of patient observation records and slow emergency responses.
Source: BBC News, 14 September 2026
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