A patient was beaten and strangled to death on a mental health ward while staff members were asleep or on unauthorized breaks, an inquest has revealed. Hugo Flint-Cahan, 34, died at the Newham Mental Health Centre (NMHC) in London on January 3, 2023, after being attacked by fellow patient Rolando Torres-Pena, 22.
Nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in a closed staff room, and healthcare assistant Anthony Onuh was asleep in a therapy room during the incident. Mr. Flint-Cahan was last seen on CCTV at 1:22 a.m. entering Torres-Pena's bedroom, disappearing from view shortly after. Torres-Pena, who had arrived on the ward five days prior and was described as paranoid, was last seen pacing the corridors at 1:26 a.m. A patient in an adjacent room was reportedly disturbed around 1:31 a.m., possibly witnessing the attack.
Torres-Pena reappeared in the corridor just before 2 a.m. wearing a towel around his waist, having removed blood-soaked trousers. Around the same time, Onuh emerged from the therapy room, and Chukwuji-Ohanachum was seen heading into the same room. It took nearly two hours for staff to discover Mr. Flint-Cahan's body. Emergency services were called at 3:37 a.m. Olagunju, who found the body, did not attempt resuscitation but instead alerted the night manager.
Falsified records indicated that Mr. Flint-Cahan was in his room at 2 a.m. and 3 a.m., despite his death occurring during this period. Onuh admitted to filling out these records without verifying patient locations. Torres-Pena pleaded guilty to manslaughter on the grounds of diminished responsibility and received a hospital order without a time limit.
Graeme Irvine, the Senior Coroner for East London, concluded that neglect was a factor in the unlawful killing. He described repeated failings by the East London NHS Trust (ELFT) as a recurring issue, noting that similar mistakes had been heard "over and over again." The coroner recommended that four staff members be referred to their regulatory body and that the Metropolitan Police review their investigation into the incident.
William Flint-Cahan, the deceased's father, stated that his son's death was preventable if the care provided had met the required standards, citing "complacency" among the staff. His brother, NHS doctor Jolyon Flint-Cahan, added that Hugo, Torres-Pena, and both families were "utterly failed" by the staff on duty and the trust's management in addressing previous staff failings.
Dr. David Bridle, Chief Medical Officer at ELFT, apologized to the Flint-Cahan family for the care failures. He acknowledged that Mr. Flint-Cahan's care fell "well below the standards" the trust aims to provide and agreed with the coroner's concerns about staff behavior and adherence to procedures. One staff member has been dismissed, and others are subject to further investigation. The trust has implemented a program to improve its inpatient culture and practices, aiming to incorporate lessons learned from the coroner's findings to enhance patient safety.
An analysis by the BBC revealed that coroners have issued 29 prevention of future deaths reports to the East London NHS Trust over the past 12 years, with more than half citing failures in risk assessment for patients. The Metropolitan Police have been contacted for comment.