A coroner has warned that further deaths could occur at an east London mental health centre where a man was killed by another patient.
Hugo Flint Cahan, 34 was strangled by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre in January 2023.
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 citing concerns about the care the two men received at the facility, which cares for acutely mentally ill men.
In the six-day inquest last month, Mr Irvine concluded that Mr Flint Cahan was unlawfully killed which was contributed to by neglect.
He has recommended that the staff be referred to their regulator and that the Met Police reviews their investigation into what happened.
As reported by the BBC, the document said that staff on the ward were asleep on the job and on their phones for long periods on the night of Mr Flint Cahan’s death.
It also outlined 14 concerns, including failing to carry out “timely and thorough observations” of patients and the falsification of records "in the safe knowledge that staff on duty would not report or escalate the deception".
One example detailed in the inquest included a member of staff filling out an observation log without checking where patients truly were.
The document added that there were delays in starting CPR on Mr Flint Cahan and that police were misled by staff as to what the patients were doing on the night of the incident.
The court heard during the inquest that staff discovered the victim almost two hours after he is believed to have been attacked.
One of the nurses said that he thought it was too late to start CPR and wanted to preserve the crime scene.
Staff were also found to have colluded with each other to take two-hour unauthorised breaks.
Mr Flint Cahan had been a patient at the facility for six months at the time of his death, while Torres-Pena had arrived on the ward just five days earlier.
The coroner raised concerns that many of the failings had been mentioned in a previous inquest.
"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", the report said.
Over the course of 12 years, local coroners have sent at least 29 Prevention of Future Deaths notices to the Trust.
As reported by the BBC, James Cahan, family solicitor and cousin to Mr Flint Cahan, said: "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.”
An NHS spokesperson told the same publication: "Patient safety incident investigations should always be published, with any necessary redactions to protect patients' identities, while making sure the lessons and learning are clear".
Dr David Bridle, chief medical officer for the ELFT, apologised to Mr Flint Cahan’s family for the failings in his care.
He said one member of staff on duty that night had been fired, while four others are under investigation by the trust.
"We will ensure the learning from the coroner's findings informs our continuing work to strengthen patient safety and care," said Dr Bridle.
ELFT and NHS England have until 19 November to respond.
Torres-Pena was given a hospital order with no limit after pleading guilty at the Old Bailey to manslaughter by diminished responsibility in 2023.
