An inquest into the death of Hugo Flint Cahan, 34, at Newham Mental Health Centre has concluded that neglect played a significant role in the fatal incident. Flint Cahan was strangled by fellow patient Rolando Torres-Pena, 22, at the facility operated by East London NHS Foundation Trust. The coroner’s investigation, conducted over six days in September, found that staff members were sleeping on duty and using their phones for extended periods on the night of the incident.
The coroner issued a Prevention of Future Deaths report identifying 14 areas of concern at the trust. These included failures to conduct timely and thorough observations of patients, falsification of records, delayed CPR response when Flint Cahan was discovered, and staff members providing misleading information to police about patient activities. The report also documented instances of staff taking two-hour unauthorized breaks while colluding with colleagues.
The coroner expressed particular concern that similar failings had been identified during a previous inquest in 2021, yet remedial measures from that investigation do not appear to have been effectively implemented. The findings noted dishonesty on a scale described as extraordinarily rare in coronial investigations. The family’s legal representative stated the public deserves clear explanation of how such failures occurred and what measures will prevent recurrence.
Towers-Pena received a hospital order with no time limit after pleading guilty to manslaughter by diminished responsibility in 2023. The trust acknowledged the identified failings as unacceptable and stated it has undertaken a significant improvement program for inpatient services. One staff member has been dismissed, while four others are under investigation. Both ELFT and NHS England have until 19 November to respond to the coroner’s report.
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