A mental health trust in east London has received a formal warning that more people may die unless it fixes its staff problems - a warning that would be more shocking if the original problem weren't, essentially, staff napping on the clock.

Hugo Flint Cahan, 34, was strangled by 22-year-old fellow patient Rolando Torres-Pena at Newham Mental Health Centre in January 2023. The facility provides care for acutely mentally ill men, which, it turns out, ideally involves staff who are awake.

Following a six-day inquest in September, senior coroner for east London Graeme Irvine concluded that neglect had more than trivially contributed to Cahan's death. On the night in question, staff on the ward were found to have been asleep on the job and on their phones for long periods - a staffing model perhaps better suited to a long-haul red-eye than an acute psychiatric ward.

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 trust's statement did not specify whether "staying awake" was part of that programme, but one assumes it's somewhere in the appendix.

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 cites delays in starting CPR on Cahan when he was discovered, staff misleading police about what the patients had been doing that night, and staff colluding 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 these failings had surfaced at a previous inquest he had conducted. "The findings in this inquest are strikingly similar to the findings of an inquest before this court in 2021," the report says. "Remedial measures reported in that case do not appear to have been implemented effectively by the trust." In other words, the sequel is tracking the original a little too faithfully.

"Findings of dishonesty on this scale are extraordinarily rare in a coronial investigation," says James Cahan, the family solicitor and Hugo's cousin. "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 coroner also criticised NHS England for not making independently produced patient safety reports at trusts publicly available - a transparency gap that, in this case, meant a commissioned report identifying some of the serious failings only came to light through the inquest.

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 that night 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. Presumably with their eyes open.