A family's profound grief has been compounded by the revelations of systemic failures within an NHS psychiatric unit where their son, Hugo Flint-Cahan, was murdered by a fellow patient. An inquest into the 34-year-old's death in January 2023 found he was unlawfully killed, with neglect contributing to the fatal attack.
The Senior Coroner for East London, Graeme Irvine, delivered a damning assessment of the Newham Centre for Mental Health, flagging 14 concerns in his Prevention of Future Deaths report. He described the trust's repeated errors in patient care as a "Groundhog Day" scenario, highlighting a "culture of dishonesty and impunity" and a "conspiracy to deceive."
During the time of the attack, two nurses were reportedly in a closed staff room, and a healthcare assistant was asleep in a therapy room, having falsified observation records to suggest he had been performing hourly checks. Hugo's body was not discovered for nearly two hours after the assault.
Hugo's family, including his stepmother Sue, an NHS radiographer, and his brother Jolyon, an anesthetist, expressed their anguish and bewilderment. "The idea that you're so unsafe that one patient could kill another while staff around them are in dereliction of their duties and breaking their regulatory codes is utterly ghastly," Jolyon stated. "And this is not just about Hugo. In fact, we know from other cases this isn't isolated. It makes you feel no-one is safe."
Hugo had a history of mental health deterioration, having been sectioned multiple times since his first psychotic episode in 2007. Despite these struggles, his family maintained hope for his recovery, especially after his admission to the Newham Centre in July 2022. However, on December 29, 2022, Rolando Torres-Peña, a 22-year-old diagnosed with bipolar affective disorder, was admitted to the same ward. Twelve days later, Hugo was dead.
CCTV footage showed Hugo interacting with Torres-Peña in the corridors and visiting his room before 1:22 am on January 3, 2023. Hugo's body was discovered at 3:19 am. Torres-Peña pleaded guilty to manslaughter by reason of diminished responsibility and received an indefinite hospital order.
The family criticized the East London NHS Foundation Trust's response, describing conversations as "bland and disinterested." They noted that a "Serious Incident Review" provided to them contained errors and included another patient's medical notes. The inquest provided much-needed scrutiny, but the family fears lessons have not been learned, pointing out that one of the nurses on duty during Hugo's death was also on duty when another patient died three years later.
"Something needs to change because the same issues seem to be arising again and again," said Hugo's cousin, James Cahan, a medical negligence lawyer. "We have seen falsification of records, poor observations and inadequate risk assessments – issues which have been highlighted to the Trust by coroners before."
David Bridle, Chief Medical Officer of the ELFT, expressed deep sympathy, stating that Hugo's care fell "well below the standards we want to provide." He confirmed one staff member had been dismissed, while others involved are under further investigation. The trust has undertaken a "significant programme of work to improve our inpatient culture, behaviors and practice" since Hugo's death.