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Coroner Warns of Future Risks at Mental Health Unit

6:09 PM ETConfirmed

Health Desk

In Short: Senior Coroner Fiona Wilcox told Westminster Coroner's Court that Lady Branson did not receive preventive anticoagulants despite a high risk of developing deep vein thrombosis.

The coroner's report, following a six-day inquest in September, highlights 14 serious concerns about the care Hugo Flint Cahan, 34, received at Newham Mental Health Centre before he was fatally attacked by Rolando Torres-Pena, 22, in January 2023.

The report identifies delays in starting CPR on Flint Cahan when he was discovered, staff misleading the police about patient activities, and collusion among staff to take unauthorized breaks.

James Cahan, Flint Cahan's family solicitor and cousin, emphasized the rarity of such findings of dishonesty in a coronial investigation, stating, "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 East London NHS Foundation Trust (ELFT) acknowledged the failings as "wholly unacceptable" and said it has undertaken a significant programme of work to improve inpatient services.

The coroner noted that the findings are strikingly similar to those from a previous inquest in 2021, indicating that remedial measures from that case were not effectively implemented.

The coroner's Prevention of Future Deaths report also includes concerns about failing to carry out timely and thorough observations of patients and falsifying records.

The coroner's office said patient safety incident investigations should always be published, with necessary redactions to protect patient identities, while ensuring the lessons and learning are clear.

The coroner's urgent warning about the failure to implement an emergency cardiac pathway could result in more deaths, highlighting the critical need for immediate action.

In a separate case, a British coroner concluded that Lady Joan Branson's death could have been prevented if she had received medication to prevent blood clots.

Senior Coroner Fiona Wilcox told Westminster Coroner's Court that Lady Branson did not receive preventive anticoagulants despite a high risk of developing deep vein thrombosis.

The coroner's findings and urgent warnings underscore the importance of addressing systemic issues in mental health care to prevent future tragedies.

What this adds

Background

What's confirmed

• The coroner's report, following a six-day inquest in September, highlights 14 serious concerns about the care Hugo Flint Cahan, 34, received at Newham Mental Health Centre before he was fatally attacked by Rolando Torres-Pena, 22, in January 2023.
• The report identifies delays in starting CPR on Flint Cahan when he was discovered, staff misleading the police about patient activities, and collusion among staff to take unauthorized breaks.
• The East London NHS Foundation Trust (ELFT) acknowledged the failings as "wholly unacceptable" and said it has undertaken a significant programme of work to improve inpatient services.
• The coroner noted that the findings are strikingly similar to those from a previous inquest in 2021, indicating that remedial measures from that case were not effectively implemented.
• The coroner's Prevention of Future Deaths report also includes concerns about failing to carry out timely and thorough observations of patients and falsifying records.
• The coroner's office said patient safety incident investigations should always be published, with necessary redactions to protect patient identities, while ensuring the lessons and learning are clear.
• The coroner's urgent warning about the failure to implement an emergency cardiac pathway could result in more deaths, highlighting the critical need for immediate action.
• In a separate case, a British coroner concluded that Lady Joan Branson's death could have been prevented if she had received medication to prevent blood clots.
• Senior Coroner Fiona Wilcox told Westminster Coroner's Court that Lady Branson did not receive preventive anticoagulants despite a high risk of developing deep vein thrombosis.
• The coroner's findings and urgent warnings underscore the importance of addressing systemic issues in mental health care to prevent future tragedies.

What's still developing

• Dianne Hocking, assistant coroner for Leicester City and South Leicestershire, has now issued a Prevention of Future Deaths (PFD) notice in relation to this issue.
• The PFD was issued before the inquest into Mr Budd’s death begins next month due to the urgency of the coroner’s concerns.
• Dooly County Coroner Brett Walls confirmed a 20-year-old man and a 23-year-old man were killed.
• Hastert, who served as House speaker from 1999 to 2o07, died over the weekend at the age of 84, according to the Kendall County Coroner’s Office.
• Kendall County, Ill., Coroner Jacquie Purcell issued a statement Monday confirming that Hastert died at his home over the weekend of natural causes.
• Coroner Brett Walls confirms those killed were both men, ages 20 years old and 23 years old.
• Victims were taken to hospitals in Crisp, Bleckley, Perry, and Atrium Health Navicent in Macon.
• Actress Hayden Panettiere died from the toxic effects of fentanyl, Xanax and several other drugs in her system, according to an autopsy completed by the Greenville County Coroner's Office in South Carolina.
• The coroner's office also found methocarbamol - a prescription muscle relaxant - and quetiapine - an antipsychotic medication that is used to treat certain mental health conditions.
• The coroner's office said emergency responders had "initiated advanced cardiac life support measures; however, resuscitation efforts were unsuccessful".
• "I do find her death would have likely been prevented, and the lack of anticoagulation did cause or contribute to her death probably," Wilcox said.
• The inquest, she said, was to "explore the facts, come to the correct conclusions and learn lessons from this," The Independent reported.

Sources

• Patient Safety Learning - the hublink
• Live5Newslink
• Mediaitelink
• Rollcalllink
• Abc45link
• BBClink
• Fox Newslink
• Ksllink
• Oxygenlink
• NBC Newslink
• Kcbdlink
• Inquirerlink
• WarpBeat — background on Pope Leo XIV Launches Mental Health Prayer Intention for October link
• WarpBeat — background on Police Watchdog Criticizes Norfolk Force Over Mental Health Call link