Coroner warns of death risks at NHS mental health unit after staff misconduct

A coroner has issued a Prevention of Future Deaths report following the death of Hugo Cahan at a mental health unit, citing 14 specific concerns regarding patient care and staff conduct. The investigation revealed that staff members were asleep on duty and using their phones for extended periods.

According to the report, staff failed to perform timely patient observations and subsequently falsified records, believing their colleagues would not report the deception. Additional failings included delays in performing CPR once Cahan was discovered, misleading police regarding patient activities, and staff colluding to take unauthorized two-hour breaks.

The coroner noted that many of these issues were raised during a previous inquest in 2021, suggesting that remedial measures implemented by the East London NHS Foundation Trust (ELFT) were not effectively applied. The report described the scale of dishonesty found as “extraordinarily rare” in coronial investigations.

In 2023, Torres-Pena pleaded guilty to manslaughter by diminished responsibility and was issued a hospital order with no time limit. The East London NHS Foundation Trust described the identified failings as “wholly unacceptable” and stated it has begun a significant program of work to improve inpatient services.