A mental health trust in east London, where a man was killed by a fellow patient, has been warned further deaths may occur unless staff issues are addressed.
Hugo Flint Cahan, 34, was strangled by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre, which provides care for acutely mentally ill men, in January 2023.
The coroner has sent a report to the Trust and NHS England raising serious concerns about the care the two men received.
It follows a six-day inquest in September during which the senior coroner for east London, Graeme Irvine, concluded that neglect had more than trivially contributed to Cahan's death.
On the night of Cahan's death, staff on the ward were found to have been asleep on the job and on their phones for long periods.
East London NHS Foundation Trust (ELFT) says the failings identified were "wholly unacceptable" and that it has undertaken a "significant programme of work" to improve inpatient services.
The coroner's Prevention of Future Deaths report highlights 14 concerns. 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".
The document also says there were delays in starting CPR on Cahan when he was discovered, that staff misled the police as to what the patients had been doing on the night of the incident, and that staff colluded with each other to take two-hour unauthorised breaks.
Torres-Pena was given a hospital order with no time limit after pleading guilty to manslaughter by diminished responsibility in 2023.
The coroner also raised concerns that many of the failings had been brought up at a previous inquest he'd conducted.
"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 says.
"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," says James Cahan, the family solicitor and Hugo's cousin.
The coroner also criticised NHS England for not making independently produced reports into patient safety at Trusts publically available.
The inquest heard that a report commissioned after Cahan's death identified some of the serious failings investigated by the coroner.
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".
In a statement, Dr David Bridle, Chief Medical Officer for ELFT, apologised to Cahan's family for the failings in his care.
He says one member of staff on duty on the night of the incident has been sacked while four others are now 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," says Dr Bridle.
ELFT and NHS England have until 19 November to respond.
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