Inquest reveals staff neglect and falsified records before patient died on East London mental health ward

During an inquest into the death of Hugo Flint-Cahan at Newham Mental Health Centre, the senior coroner determined that the patient was unlawfully killed after a fellow patient, Rolando Torres-Pena, strangled him. Evidence showed that on the night of the incident, two nurses and a nursing assistant were either sleeping, on break or falsifying patient observation records, leaving the ward largely unattended. CCTV captured the attacker moving through the corridor and entering the victim's room, while staff remained in the staff room or therapy area.

The night manager raised the alarm after discovering the victim, but emergency services were called only after a delay, and CPR was not initiated until several minutes later. The East London NHS Trust has been instructed to refer four staff members to their regulator and to cooperate with a Metropolitan Police review of the investigation.