A coroner’s inquest concluded that Hugo Flint Cahan, 34, was unlawfully killed at Newham Mental Health Centre in east London, with neglect contributing to his death. Cahan was fatally attacked by fellow patient Rolando Torres-Pena, 22, who had arrived on the ward five days prior. Torres-Pena subsequently pleaded guilty to manslaughter on grounds of diminished responsibility and received a hospital order without time limit.
The inquest revealed significant lapses in supervision on the night of the incident. Two nurses and a nursing assistant were on duty on Topaz ward, which serves men with acute mental health issues. One nursing assistant slept for two hours in a therapy room, while the two nurses were in the staff room with the door shut during a period when multiple patients were observed walking the corridor unattended. Patients were supposed to be checked hourly, but observation records falsely indicated Cahan was in his bed awake at the time he was being attacked.
CCTV footage showed Torres-Pena walking the corridor without trousers, which the coroner noted were soaked in blood. Cahan was discovered nearly two hours after the attack at 03:19. The staff member who found him did not attempt CPR or immediately raise an alarm. Emergency services were not called until 03:37, and CPR did not begin until 03:45. Cahan was declared dead at 04:41.
The coroner issued a narrative conclusion criticizing repeated failures by the Trust, recommending that four staff members be referred to their regulator and that the Metropolitan Police review their investigation. The coroner noted hearing evidence of consistent errors including falsification of patient observation records and slow emergency responses across multiple cases. Over the past 12 years, coroners have issued at least 29 Prevention of Future Deaths notices to the Trust, with more than half citing failures in properly assessing patient risk and poor communications between staff and agencies. Recent reports from 2021 and 2024 specifically highlighted concerns about missed observations and falsified records.
The Trust stated it has undertaken a program to improve inpatient culture, behaviors, and practice. Cahan’s family described the failures as dangerous and preventable, emphasizing the impact of systemic issues on care quality.
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