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On the evening when Cahan passed away, it was discovered that ward staff had been sleeping during their shifts and spending extensive periods on their phones. The East London NHS Foundation Trust (ELFT) acknowledged these failures as “wholly unacceptable” and stated that it has since initiated a comprehensive programme aimed at enhancing inpatient services.
The coroner’s Prevention of Future Deaths report outlined 14 specific concerns. Among them were inadequate and untimely monitoring of patients, followed by falsification of records, seemingly undertaken with the confidence that on-duty staff would neither report nor escalate these deceptions. Additional issues highlighted in the report included delays in administering CPR to Cahan after he was found, misleading information given to the police about the activities of patients on the night of the incident, and staff complicity in taking unauthorized two-hour breaks.
In 2023, Torres-Pena received a hospital order without a fixed duration after admitting guilt to manslaughter by diminished responsibility. The coroner noted that many of the identified inadequacies had already been raised in a previous inquest he had conducted. The report pointed out that the findings in this case bore a strong resemblance to those from a prior inquest in 2021, adding that the supposed remedial actions required were not effectively carried out by the trust.
James Cahan, a family solicitor and cousin of Hugo, emphasized the gravity of the situation by stating, “Findings of dishonesty on this scale are extraordinarily rare in a coronial investigation. The public are entitled to expect a clear explanation of how this was allowed to happen and what is being done to ensure it never happens again.
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