ELFT and NHS England must answer coroner over Newham mental health death

East London NHS Foundation Trust (ELFT) and NHS England have been given a deadline of 19 November 2026 to answer a Prevention of Future Deaths report submitted by senior coroner for east London Graeme Irvine. The report follows the inquest into the death of Hugo Flint Cahan, 34, who was strangled by 22‑year‑old patient Rolando Torres‑Pena at Newham Mental Health Centre in January 2023.

Background to the inquest

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The six‑day inquest, reported by the BBC and The Standard, concluded that Mr Flint Cahan was unlawfully killed and that neglect contributed to the outcome. The coroner noted that the victim had been a patient for six months, while the attacker had arrived on the ward only five days before the incident. Torres‑Pena later received a hospital order after pleading guilty to manslaughter by diminished responsibility at the Old Bailey.

Coroner’s concerns

Graeme Irvine’s report lists 14 specific concerns. The Standard said the document highlighted failure to carry out timely and thorough observations, and the falsification of records by staff who knew their deception would not be reported. One example described a nurse completing an observation log without confirming patient locations. The report also recorded two‑hour unauthorised breaks, staff sleeping on duty and using phones, and a delay of almost two hours before the victim was discovered.

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We will ensure the learning from the coroner's findings informs our continuing work to strengthen patient safety and care.

Dr David Bridle, chief medical officer, ELFT

Dr David Bridle, chief medical officer for ELFT, told The Standard that one staff member had been dismissed and four others were under investigation. He apologised to Mr Flint Cahan’s family and said the trust would act on the coroner’s recommendations.

Potential next steps

If ELFT and NHS England fail to provide satisfactory responses by the November deadline, the coroner may issue further enforcement notices. The Metropolitan Police have also been asked to review their investigation, as noted in the report. Families and advocacy groups are likely to monitor the trust’s actions closely, seeking evidence that the identified failings are corrected.