Staff slept while patient killed at NHS mental health unit.

A damning inquest has revealed a night of shocking neglect at an NHS mental health unit in east London, where staff allegedly falsified records, slept, and used their phones while one patient was brutally killed by another. Hugo Flint-Cahan, a 34-year-old man receiving treatment at the Newham Mental Health Centre (NMHC), run by the East London NHS Trust (ELFT), was the victim of a fatal attack by 22-year-old Rolando Torres-Pena. Hugo’s grieving family have expressed profound shock and distress at what they describe as "dangerous" failures in his care, highlighting systemic issues that have plagued the Trust for years.

The Trust has stated it has undertaken a "significant programme of work" to improve its "inpatient culture, behaviours and practice" in response to the findings. However, the Senior Coroner for East London, Graeme Irvine, delivered a narrative conclusion finding that Hugo was unlawfully killed, with neglect contributing to his death. He has recommended that four members of staff be referred to their professional regulator and that the Metropolitan Police review their investigation into the events of that tragic night. The coroner’s criticism extended beyond Hugo’s death, citing repeated failures by the Trust in numerous patient deaths, describing the situation as akin to "groundhog day" due to recurring errors, including the falsification of patient observation records and alarmingly slow emergency responses.

Hugo, who had been a patient at the NMHC for six months, was strangled in the early hours of January 3, 2023, by Torres-Pena, who had been admitted to the ward just five days prior. Torres-Pena later pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility and was issued a hospital order without a time limit.

On the night of Hugo’s death, the Topaz ward, an inpatient unit for men with acute mental health issues, was staffed by just two nurses and one nursing assistant. Evidence presented at the inquest revealed that Torres-Pena was pacing the corridor, under the delusion he was about to leave the unit. Hugo was also noted to be unsettled, with CCTV footage showing him wandering the corridor alone after 1:00 AM. The last time he was seen alive on camera was at 1:22 AM. It is believed he entered Torres-Pena’s room shortly thereafter.

At 1:26 AM, Torres-Pena was seen walking the corridor and then entered Hugo’s empty room before disappearing from view. While the exact time of the attack remains unknown, at 1:31 AM, a patient in the room adjacent to Torres-Pena’s emerged, appearing disturbed by something and looking up and down the corridor. Crucially, no staff members were visible. This patient was then observed watching something out of shot, which is believed to be the moment Hugo was being attacked.

During this critical period, the two nurses on duty, Rosemary Chukwuji-Ohanachum and Raji Olagunju, were in the staff room with the door shut. Despite three patients being observed walking the corridors, no staff were present. Adding to the dire neglect, nursing assistant Anthony Onuh was found to have been asleep for two hours in the therapy room.

Just before 2:00 AM, Torres-Pena was again seen walking the corridor, notably without trousers. The coroner revealed that Torres-Pena had removed them because they were soaked in blood. In stark violation of protocol, patients on the ward should have been checked hourly. However, the observation log for the ward falsely indicated that at 2:00 AM, Hugo was in his bed, awake. Onuh later admitted to the coroner that he had falsified this record without verifying the location of any patients.

Around the same time, CCTV footage captured Onuh emerging from the therapy room with his bedding. He was seen speaking with Torres-Pena, while nurse Chukwuji-Ohanachum walked past with her blankets. She informed the coroner that she was going to the therapy room to sleep during an unauthorized two-hour break.

Hugo was discovered at 3:19 AM by nurse Olagunju, almost two hours after the attack. In a shocking revelation, Olagunju did not attempt CPR or raise an immediate alarm. Instead, she went to find the unit’s night manager, Alex Obamwonyi, who was on a neighbouring ward. Obamwonyi stated that upon finding Hugo, he observed the patient was not breathing and had no pulse. He then raised the alarm but proceeded to lock the door to Hugo’s room, believing it was too late for CPR and wanting to preserve the crime scene.

Emergency services were not called until 3:37 AM, and CPR was only initiated at 3:45 AM. Witnesses at the inquest described chaotic scenes, with nurse Chukwuji-Ohanachum reportedly screaming and throwing herself on the ground, requiring restraint by other staff. One staff member was left to perform chest compressions on Hugo alone until exhaustion forced them to stop. Hugo was officially declared dead at 4:41 AM.

Hugo’s father, William Flint Cahan, who attended the inquest daily with other family members, described the staff’s actions as demonstrating "complacency" and a profound lack of care. He firmly believes his son’s death was "preventable had the level of care been as it should have been." Hugo’s brother, Jolyon, an NHS doctor himself, described the "litany of failures, both incompetence and dishonesty, that pervaded the care of both patients [Hugo and Torres-Pena] was harrowing."

The inquest also brought to light a deeply concerning pattern of failures at the East London NHS Trust. Over the past 12 years, local coroners have issued at least 29 Prevention of Future Deaths (PFD) notices to the Trust. These notices are issued when a coroner identifies issues that, if unaddressed, could lead to further fatalities. An analysis of these reports by the BBC, covering both inpatient and community services, revealed that in over half of the cases, there was a failure to properly assess patient risk. Poor communication between staff, external agencies, and families was also repeatedly highlighted.

The most severe warnings consistently focused on poorly executed observations and falsified records – fundamental elements of patient safety. A 2021 report by the coroner who presided over the Flint-Cahan inquest had already warned of a "culture of impunity" at the Trust, where "inaccurate and misleading recording of clinical records was tolerated." Alarmingly, in 2024, two further reports again highlighted missed observations with subsequent falsification of records to suggest patients had been checked. Despite assurances from the Trust and the introduction of extensive training programmes and quality checks in response to PFDs, a fourth report in 2025, concerning the death of a young woman, once again identified falsified observation records. The coroner in that case noted that "despite assurances" from the Trust, the inquest had "revealed widespread concerns" about how observations were carried out across two wards.

Other critical issues raised in these reports include delays in responding to emergencies, with instances of delayed resuscitation and, on one occasion, nursing staff administering chest compressions to a patient’s stomach instead of their chest. Brian Dow of the mental health charity Rethink is advocating for a national register of patient safety to monitor the quality of care provided by mental health units across the country. He lamented, "We have been here before" with poor observations, falsified records, and unacceptable care, emphasizing the urgent need for a "better approach to patient safety in what are the most difficult and most vulnerable wards with the people who are the most unwell."

In a statement, Dr. David Bridle, Chief Medical Officer at ELFT, expressed the Trust’s deep sorrow to Hugo’s family for the failings in his care. He described the actions of the staff identified by the coroner as "wholly unacceptable and do not reflect the standards, values or behaviours we expect." Dr. Bridle stated that the Trust has actively worked to improve its services and will ensure that the lessons learned from the coroner’s findings inform their ongoing efforts to enhance patient safety and care.