An inquest concluded that Hugo Flint-Cahan, 34, was unlawfully killed at Newham Mental Health Centre in east London, operated by East London NHS Trust, when he was fatally attacked by fellow patient Rolando Torres-Pena, 22, on 3 January 2023. Torres-Pena, who had been on the ward for five days, pleaded guilty to manslaughter on grounds of diminished responsibility and received a hospital order without time limit.
The inquest revealed significant failures in patient supervision and record-keeping 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 approximately two hours in a therapy room while patients were unattended. The two nurses retreated to a staff room with the door closed and one took an unauthorized break, leaving the ward unsupervised. Staff falsified observation logs, which were supposed to document hourly patient checks, recording Hugo as awake in his bed at 02:00 when he had already been attacked. Hugo was discovered nearly two hours after the assault and emergency services were not called until 03:37.
Senior Coroner for East London Graeme Irvine issued a narrative conclusion of unlawful killing contributed to by neglect. The coroner recommended that four staff members be referred to their regulator and that the Metropolitan Police review their investigation. The coroner noted this case represented recurring systemic failures, describing the pattern as repetitive with the same errors occurring repeatedly, including falsified patient records and delayed emergency responses.
Records show that over the preceding 12 years, local coroners sent at least 29 Prevention of Future Deaths notices to the Trust. Analysis of these reports identified that more than half involved failures to properly assess patient risk to themselves or others. Common issues included poor communication between staff, other agencies, and families, along with inadequately conducted observations and falsified records. The Trust stated it has addressed certain issues identified in the inquest and launched an investigation into the implicated staff members.
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