News
A Coroner has issued a Prevention of Future Deaths (PFD) report following the inquest into the death of Hugo Flint-Cahan, a 34-year-old mental health patient who was unlawfully killed by another patient at the Newham Centre for Mental Health in January 2023. Hugo’s family are being represented by Thomson Snell & Passmore’s Clinical Negligence team.
The report raises serious concerns about patient safety, the falsification of observation records, staff conduct and organisational learning within mental health services, and has been sent to East London NHS Foundation Trust and NHS England.
The PFD report follows the conclusion of an inquest, at which Senior Coroner for East London, Graeme Irvine, found that Hugo’s death was the result of an unlawful killing and that neglect had contributed to his death. The Coroner concluded that the frequency and quality of observations carried out on both Hugo and the patient who killed him represented a “gross failure in care” which, on the balance of probabilities, more than trivially contributed to his death.
Hugo had been an inpatient at the Newham Centre for Mental Health since June 2022. In the early hours of 3 January 2023, he entered another patient’s room and was fatally assaulted. CCTV and other evidence examined during the inquest revealed significant failures in patient observations, record keeping and emergency response procedures on the ward.
In his PFD report, the Coroner identified 14 areas of concern which he believes create a continuing risk of future deaths if action is not taken. These included failures to obtain important information from Hugo’s family to assist with his treatment, failures to properly supervise patient leave, inadequate enforcement of policies designed to prevent patients entering each other’s rooms, poor-quality patient observations, falsification of observation records and the use of mobile phones and headphones by staff while on duty.
The report also highlighted evidence that staff conspired to facilitate unauthorised two-hour sleep breaks during night shifts, leaving the ward dangerously understaffed, as well as significant delays in calling emergency services and commencing CPR after Hugo was discovered unresponsive. The Coroner further raised concerns that police investigating the incident were misled during interviews with nursing staff. During the inquest he referred to “a culture of dishonesty and impunity”, “a conspiracy to deceive” and “an appallingly low standard of care.”
Of particular concern, the Coroner noted that the findings were “strikingly similar” to those identified during an earlier inquest in 2021 and stated that measures previously reported by the Trust did not appear to have been implemented effectively. He also raised concerns about restrictions on the wider publication of independent patient safety investigations, warning that this prevents meaningful learning across the NHS.
The inquest heard evidence of repeated failures in basic clinical observation and supervision, concerns regarding management oversight and auditing procedures, and wider issues relating to governance and organisational learning. The Coroner described hearing evidence of similar failings repeatedly over a number of years, leading him to characterise the situation as “groundhog day” during the inquest proceedings.
Speaking on behalf of the Flint-Cahan family, James Cahan, Partner in the Clinical Negligence team at Thomson Snell & Passmore, said: “We are grateful to the Coroner for the exceptional care and thoroughness with which he approached this investigation. The Prevention of Future Deaths report reflects a meticulous examination of the evidence and raises serious concerns about patient safety. This was not a case involving isolated mistakes or a single error of judgement. The Coroner identified concerns that extended across observation practices, record keeping, supervision, governance and organisational learning. Particularly troubling to us, are the findings relating to dishonest records and the suggestion that staff were able to falsify observations in the expectation that colleagues would not challenge or report that conduct. Findings of that nature are exceptionally rare and should concern everyone involved in the delivery of mental health care. The overriding priority now must be ensuring that these findings lead to lasting change and improved patient safety.
“The Coroner has now directed that several members of staff be referred to their professional regulator, yet those findings have only emerged almost four years after the events in question. That inevitably gives rise to concerns about whether other vulnerable patients may have been exposed to the same dangerous practices in the intervening period.”
The Coroner’s report also raises broader questions about transparency and learning within mental health services. One of the concerns identified is that independent patient safety reports commissioned by NHS England are not routinely made available to the wider public, preventing other organisations from learning from serious incidents.
Commenting on this issue, James added: “Many of these concerns are not new: similar issues have been raised in previous Prevention of Future Deaths reports directed to this Trust, and we see comparable concerns all too frequently in our own investigations into deaths in hospital. Earlier this week I spoke to another family about the death of their mother on a different ward at the Newham unit, just weeks after Hugo, missed observations and failures of basic patient care were at the heart of that tragic case as well, and I was saddened to hear that, yet again, it took a review of the CCTV, by the coroner, to uncover the full extent of the problems leading to her death.
“These two cases appear to show the issues are not confined to one ward. The wider question now is whether the failings identified in both of these cases are confined to just this unit, or whether similar practices around patient observations in mental health units exist elsewhere, but remain undetected. It should not take external scrutiny of CCTV footage, two independent reviews and a full inquest to uncover dangerous practices that leave vulnerable patients without the supervision intended to keep them safe.
“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 case highlights the challenges many bereaved families face when seeking answers following a death in healthcare or state care settings. While Thomson Snell & Passmore regularly assists families through complex inquests and related legal claims, support is also available from specialist charities. Organisations such as Action against Medical Accidents (AvMA) provide valuable guidance and assistance to families seeking access to legal help and support during the inquest process.
Hugo’s family hope that the publication of this PFD report will lead not only to meaningful change within the organisations addressed by the Coroner, but also to broader action across mental health services nationally. The concerns identified in this case, including failures in patient observations, record keeping, staffing practices, risk management and organisational learning, have all featured in previous PFDs issued in relation to mental health care. With coroners continuing to identify similar failings years after earlier warnings were issued, the family believe there is an urgent need for national action to ensure lessons are properly implemented and sustained, so that other vulnerable patients are protected and no other family has to experience the tragedy they have endured.
East London NHS Foundation Trust and NHS England must now formally respond to the Coroner’s concerns and set out what action they intend to take to reduce the risk of similar deaths occurring in future.
