Staff at an NHS mental health unit in east London were found to have falsified records, slept, and used their phones on the night a patient was killed by another, an inquest has heard. Hugo Flint-Cahan, 34, was fatally attacked by 22-year-old Rolando Torres-Pena at Newham Mental Health Centre (NMHC), run by the East London NHS Trust (ELFT).
The coroner concluded that Hugo was unlawfully killed, with neglect contributing to his death. Four members of staff were recommended for referral to their regulator, and the Metropolitan Police were advised to review their investigation into the incident.
Hugo, a patient at NMHC for six months, was strangled in the early hours of 3 January 2023 by Torres-Pena, who had arrived on the ward five days prior. Torres-Pena pleaded guilty to manslaughter on the grounds of diminished responsibility and received a hospital order without time limit.
The inquest heard that on the night of Hugo's death, two nurses and a nursing assistant were on duty. Nursing assistant Anthony Onuh admitted to the coroner that he filled out observation forms without checking patients' locations, and CCTV showed him emerging from a therapy room with bedding. Nurse Rosemary Chukwuji-Ohanachum also told the coroner she was going to sleep in the therapy room during an unauthorised two-hour break.
Hugo was discovered at 03:19 by nurse Raji Olagunju, almost two hours after the attack. Emergency services were called at 03:37, and CPR began at 03:45. Hugo was declared dead at 04:41.
The Senior Coroner for East London, Graeme Irvine, criticised repeated failures by the Trust in multiple patient deaths, noting a pattern of errors including falsified patient observation records and slow emergency responses. Over the past 12 years, local coroners have issued at least 29 Prevention of Future Deaths notices to the Trust, with reports highlighting issues such as failure to assess patient risk, poor communication, and poorly carried out observations with falsified records.