"Around 2am, Torres-Pena reappeared in the corridor wearing a towel around his waist after he removed his blood-soaked trousers (CCTV of the moment is pictured)
Hugo's father, William Flint-Cahan, who attended each day of the inquest with other family members said his son's death was 'preventable had the level of care been as it should have been' and there was 'complacency' by staff
Graeme Irvine, the Senior Coroner for East London, concluded neglect was a factor in the unlawful killing at an inquest on Monday.
The coroner described repeated failings by the Trust as 'groundhog day' as he heard evidence of the same mistakes 'over and over again'.
He recommended four members of staff be referred to their regulator and that the Metropolitan Police review their investigation into the incident.
His brother, NHS doctor Jolyon Flint-Cahan, made a statement after the inquest.
He said: 'Hugo, the patient that killed him, and both of our families were utterly failed by the staff on duty that night and the lack of ability by the Trust management to investigate their own staff's failings to previous deaths.'
His father, William Flint-Cahan, who attended each day of the inquest with other family members said his son's death was 'preventable had the level of care been as it should have been' and there was 'complacency' by staff.
Dr David Bridle, Chief Medical Officer at ELFT, said the Trust was deeply sorry to Mr Flint-Cahan's family for the failings in his care.
He said the trust had undertaken a significant programme of work to 'improve our inpatient culture, behaviours and practice'."
Framing: assertive ·
First seen: 2026-09-15 ·
Last seen: 2026-09-15 ·
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