Inquest findings and conclusion
Senior Coroner for East London Graeme Irvine reached a narrative conclusion that the death was unlawful and that neglect contributed to it. The inquest established the identities of the two patients involved: the man who died, Hugo Flint-Cahan, 34, and the patient who attacked him, Rolando Torres-Pena, 22.
The inquest heard that Mr Flint-Cahan had been a patient on the ward for six months and that Mr Torres-Pena had arrived on the ward five days before the fatal attack. The assault took place in the early hours of 3 January 2023.
Failings on the night
The inquest heard evidence about staffing and observation on the ward shortly before and during the incident. Two nurses were reported to have been in a staff room with the door shut while a nursing assistant was asleep in a therapy room for about two hours, the inquest heard. The patient-observation log recorded Mr Flint-Cahan as awake in bed at 02:00, but the inquest heard that the record was false and that the assistant admitted completing it without checking patients’ locations.
Mr Flint-Cahan was discovered at about 03:19. The inquest heard that emergency services were called at 03:37, that cardiopulmonary resuscitation began at 03:45 and that he was declared dead at 04:41. The coroner highlighted repeated failures, including falsified observation records and slow emergency responses, and described the recurrence of such problems as “ground hog day”, the inquest heard.
Legal outcome for the attacker and coroner’s recommendations
The inquest record includes the legal outcome separate to the coroner’s conclusion. Mr Torres-Pena pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility and was given a hospital order with no time limit. The coroner recommended that four members of staff be referred to their regulator and that the Metropolitan Police review its investigation into what happened that night.
Those recommendations were made in the context of broader criticism at inquest level about repeated shortcomings in some aspects of patient care and ward supervision, as outlined during the hearing.
Trust response and patient-safety work
The chief medical officer at East London NHS Foundation Trust, Dr David Bridle, said the trust was deeply sorry to the family and described the staff actions identified by the coroner as wholly unacceptable. He said learning from the inquest findings would inform continuing patient-safety work and that the trust had undertaken work to strengthen patient safety and care.
The coroner’s narrative finding, the account of events on the ward heard at inquest, and the trust’s response together highlight an official scrutiny of how care and supervision were managed on the night and of the need for lessons to be applied to prevent recurrence.
The inquest record and the coroner’s recommendations place further steps in the hands of regulators and the police to consider individual professional accountability and any necessary reviews of investigative practice. The case underlines continuing attention to patient safety and oversight in inpatient mental-health settings.
