Inquest: Staff slept and falsified records during NHS murder
An inquest into the death of 34-year-old Hugo Flint-Cahan at an NHS mental health unit reveals staff slept, used phones, and falsified observation logs.
Stock photo for illustration only, not from the actual event
- Hugo Flint-Cahan, 34, was strangled to death at Newham Mental Health Centre on Jan 3, 2023.
- Rolando Torres-Pena pleaded guilty to manslaughter and received a hospital order.
- Inquest found staff were sleeping, using phones, and falsifying patient observation records.
- Coroner highlighted severe neglect and recommended referring four staff members to regulators.
Staff members falsified observation records, slept on duty, and used their mobile phones on the night a patient was killed by another at an NHS mental health unit in east London, an inquest has been told. Hugo Flint-Cahan, 34, was receiving treatment at the Newham Mental Health Centre (NMHC), operated by the East London NHS Trust (ELFT), when he was fatally attacked by 22-year-old Rolando Torres-Pena.
In a narrative conclusion, the coroner found that Flint-Cahan was unlawfully killed, with neglect contributing to his death. The coroner recommended that four staff members be referred to their regulator and that the Metropolitan Police review their investigation into the events of that night. Flint-Cahan had been a patient at the facility for six months before being strangled in the early hours of January 3, 2023, by Torres-Pena, who had arrived on the ward just five days earlier.
This tragic incident within a psychiatric care facility highlights severe systemic vulnerabilities in monitoring vulnerable patients who require constant acute observation. When medical staff neglect their foundational duties, it not only shatters public trust in healthcare systems but also underscores the urgent need for stringent oversight, transparent accountability, and reliable safety protocols to prevent such preventable fatalities.
On the night of the incident, Topaz ward—an inpatient unit for men with acute mental health issues—had two nurses and a nursing assistant on duty. CCTV footage captured Torres-Pena pacing the corridor while Flint-Cahan was also unsettled, with the last live sighting recorded at 01:22. The attack is believed to have occurred shortly after he entered Torres-Pena's room.
At 01:31, a patient from an adjacent room emerged looking distressed while no staff members were visible in the corridor. During this period, nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were inside the staff room with the door shut, while nursing assistant Anthony Onuh slept for two hours in the therapy room. Despite missed checks, the ward observation log falsely recorded that Flint-Cahan was awake in bed at 02:00.
"Hugo was discovered at 03:19 by nurse Olagunju, almost two hours after he was attacked. He didn't attempt CPR or raise the alarm..."
BBC Health
Flint-Cahan was discovered at 03:19 by nurse Olagunju, nearly two hours after the attack took place. Olagunju did not attempt CPR or immediately raise the alarm, instead seeking the night manager, Alex Obamwonyi, on a neighbouring ward. Emergency services were called at 03:37, and chest compressions finally commenced at 03:45 amid chaotic scenes described by witnesses.
An analysis of records over the past 12 years shows local coroners have issued at least 29 Prevention of Future Deaths (PFD) notices to the Trust. The warnings repeatedly flagged poor observation practices and falsified records, despite the Trust claiming extensive training programmes had been implemented.
Source: BBC Health
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