An east London mental health trust has been formally warned by a coroner that further patient deaths could occur unless serious staff failings are addressed, following the killing of a man by a fellow patient.

Hugo Flint-Cahan, 34, was strangled by 22-year-old Rolando Torres-Pena in January 2023 at Newham Mental Health Centre, an East London NHS Foundation Trust (ELFT) facility providing care for acutely mentally ill men. In earlier reporting, we referred to Mr Flint-Cahan without a hyphen in his surname.

Following a six-day inquest in September, the senior coroner for east London, Graeme Irvine, concluded that neglect contributed more than trivially to Mr Flint-Cahan's death.

Coroner Irvine has now sent a Prevention of Future Deaths report to ELFT and NHS England, detailing 14 serious concerns regarding the care provided to both men.

According to the report, ward staff on duty that night were found to have been asleep and using their mobile phones for extended periods instead of monitoring patients. Staff failed to conduct timely and thorough observations and subsequently falsified records "in the safe knowledge that staff on duty would not report or escalate the deception".

The coroner also found that staff colluded to take unauthorised two-hour breaks, delayed administering CPR when Mr Flint-Cahan was discovered, and misled attending police officers about what the patients had been doing earlier that evening.

Torres-Pena was sentenced to an indefinite hospital order in 2023 after pleading guilty to manslaughter by diminished responsibility.

Coroner Irvine warned that these issues had arisen previously, noting: "The findings in this inquest are strikingly similar to the findings of an inquest before this court in 2021, remedial measures reported in that case do not appear to have been implemented effectively by the trust."

James Cahan, the family's solicitor and Mr Flint-Cahan's cousin, stated: "Findings of dishonesty on this scale are extraordinarily rare in a coronial investigation. 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."

The coroner also criticised NHS England for not routinely publishing independent patient safety reports, after the inquest heard an investigation commissioned after the death had already identified several key failings. An NHS spokesperson said that patient safety incident investigations should always be published with necessary redactions to ensure learning is clear.

Dr David Bridle, Chief Medical Officer for ELFT, apologised to the family and confirmed that one staff member has been dismissed while four others remain under trust investigation. ELFT and NHS England have until 19 November to respond to the coroner's report, and I will continue to report on their responses as they are published.