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Coroner Warns of Future Risks at Mental Health Unit
Confirmed
In Short: A coroner has issued a warning that further deaths may occur at a mental health unit unless staff issues are addressed.
The coroner's report, following a six-day inquest in September, highlights serious failings at Newham Mental Health Centre in east London, where Hugo Flint Cahan, 34, was fatally attacked by Rolando Torres-Pena, 22, in January 2023.
The senior coroner for east London, Graeme Irvine, concluded that neglect had more than trivially contributed to Flint Cahan's death.
The report sent to the Trust and NHS England raises 14 concerns, including delays in starting CPR on Flint Cahan when he was discovered, staff misleading the police, and staff collusion to take unauthorised breaks.
The coroner's Prevention of Future Deaths report also notes that staff falsified records, knowing that on-duty staff would not report or escalate the deception.
James Cahan, the family solicitor and Hugo's cousin, 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."
East London NHS Foundation Trust (ELFT) acknowledged that the failings identified were "wholly unacceptable" and that it has undertaken a "significant programme of work" to improve inpatient services.
The report also states that the findings in this inquest are strikingly similar to those of a previous inquest in 2021, indicating that remedial measures reported in that case do not appear to have been implemented effectively by the trust.
An NHS spokesperson said, "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."
What this adds
The coroner's report adds that the failure to implement an emergency cardiac pathway could result in more deaths, leading to an urgent Prevention of Future Deaths notice issued by Assistant Coroner Dianne Hocking for Leicester City and South Leicestershire.
Background
A coroner has issued a warning that further deaths may occur at a mental health unit unless staff issues are addressed.
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.
What's confirmed
- A coroner has issued an urgent warning that the failure to implement an emergency cardiac pathway could result in more deaths.
- 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.
- Kendall County, Ill., Coroner Jacquie Purcell issued a statement Monday confirming that Hastert died at his home over the weekend of natural causes.
What's still developing
- These include failing to carry out "timely and thorough observations" of patients, then falsifying records "in the safe knowledge that staff on duty would not report or escalate the deception".
- 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.
- 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".
- The death of Richard Branson's wife, Lady Joan Branson, could have been prevented if she had received medication to prevent blood clots, a British coroner reportedly found.
- Senior Coroner Fiona Wilcox told Westminster Coroner's Court earlier this month that Lady Branson did not receive preventive anticoagulants, commonly known as blood thinners, at the hospital despite a "very high risk of developing deep vein thrombosis," according to the outlet.
- A British coroner concluded Lady Joan Branson's death likely could have been prevented with preventive blood-thinning medication. (Axelle/Bauer-Griffin/FilmMagic) According to testimony during the legal inquest, Lady Branson's biggest risk factors included her immobility after a fracture following her fall.
- Staff slept while patient killed at NHS mental health unit Trump says 'threat' led US to pull bombers from RAF Fairford Author and former politician Jeffrey Archer dies aged 86 Tories pledge £10bn 'Britannia Shield' air defence system Europe is pouring billions into space.
Sources
- Medical Republiclink
- Patient Safety Learning - the hublink
- Live5Newslink
- Mediaitelink
- Rollcalllink
- Abc45link
- BBClink
- Fox Newslink
- Warpbeatlink
- Ksllink
- Oxygenlink
- NBC Newslink
- Kcbdlink
- WarpBeat — background on Coroner Warns of Future Risks at Mental Health Unit link
- WarpBeat — background on Coroner Warns of Future Risks at Mental Health Unit link