Coroner flags 14 concerns at unit where patient was strangled — SkimNews
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- Hugo Flint Cahan, 34, was strangled by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre in January 2023; Torres-Pena pleaded guilty to manslaughter by diminished responsibility and received a hospital order with no time limit.
- Senior coroner Graeme Irvine concluded neglect more than trivially contributed to the death after a six-day inquest in September, issuing a Prevention of Future Deaths report with 14 concerns — including staff asleep on the job and on phones, falsified observation records, delayed CPR, and staff misleading police.
- The coroner found the failings "strikingly similar" to a 2021 inquest he conducted, noting that remedial measures reported in that case "do not appear to have been implemented effectively" by the trust.
- East London NHS Foundation Trust (ELFT) has sacked one staff member on duty that night and is investigating four others; Chief Medical Officer Dr David Bridle apologised to Flint Cahan's family and called the failings "wholly unacceptable."
- The coroner criticised NHS England for not making independently produced patient safety reports publicly available, with ELFT and NHS England given until 19 November to respond.
- James Cahan, the family solicitor and Hugo's cousin, said findings of dishonesty on this scale are "extraordinarily rare in a coronial investigation" and that the public is entitled to a clear explanation.
Why it matters: The coroner's finding that 2021 remedial measures were never properly implemented reveals a pattern of unaddressed systemic failure at ELFT rather than a one-off lapse. With one staff sacked, four under investigation, and NHS England facing a 19 November response deadline, the case also puts scrutiny on why independently produced patient safety reports are not made public.
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