An inquest has found that Hugo Flint-Cahan, 34, was neglected before being beaten and strangled to death by a fellow patient, Rolando Torres-Pena, 22, on a mental health ward in east London in January 2023. Staff at Newham Mental Health Centre, run by East London NHS Foundation Trust, were meant to check on patients hourly, but two nurses were in a closed staff room and a healthcare assistant was asleep in a therapy room while the attack took place, and records were later falsified to suggest checks had been carried out. The case has raised serious concerns about patient safety and staff conduct within NHS mental health services.

CCTV showed Mr Flint-Cahan entering Torres-Pena's room shortly after 1.20am, with Torres-Pena reappearing later wearing only a towel after removing blood-soaked trousers; it took staff almost two hours to find the body, and paramedics were not called until 3.37am, with Mr Flint-Cahan pronounced dead at 4.41am. Torres-Pena admitted manslaughter by diminished responsibility and was given an indefinite hospital order. The senior coroner, Graeme Irvine, ruled the death an unlawful killing contributed to by neglect, describing repeated Trust failings as "groundhog day," and recommended four staff be referred to their professional regulators and that the Metropolitan Police review its investigation. Mr Flint-Cahan's family said the death was preventable and reflected "complacency" by staff.