Staff slept and falsified records as patient died in NHS attack, inquest hears

An inquest has revealed that nursing staff at an NHS mental health unit in east London slept, used their phones, and falsified patient records on the night one resident killed another. Hugo Flint-Cahan, 34, was strangled by fellow patient Rolando Torres-Pena at the Newham Mental Health Centre, which is operated by the East London NHS Trust (ELFT).

The coroner, Graeme Irvine, returned a narrative conclusion stating that Hugo’s death was unlawful and contributed to by neglect. He recommended that four members of staff be referred to their regulatory body and urged the Metropolitan Police to review their initial investigation.

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

CCTV footage examined during the proceedings showed Hugo wandering the corridors alone after 01:00. His last known appearance was at 01:22. Shortly after, Torres-Pena entered Hugo’s vacant room and disappeared from view. At 01:31, a patient in an adjacent room emerged, appearing disturbed, though no staff were visible. It is believed the assault occurred during this window.

Meanwhile, two nurses—Rosemary Chukwuji-Ohanachum and Raji Olagunju—were in the staff room with the door closed. Nursing assistant Anthony Onuh was found asleep in the therapy room for two hours. Although patients were supposed to be checked hourly, the observation log falsely recorded that Hugo was awake in his bed at 02:00.

Onuh admitted to the coroner that he completed the form without verifying patient locations. CCTV captured him leaving the therapy room with his bedding, while Nurse Chukwuji-Ohanachum was also seen carrying blankets, stating she was heading to the therapy room for an unauthorized two-hour sleep.

Hugo was discovered at 03:19 by Nurse Olagunju, nearly two hours after the attack. Witnesses described chaotic scenes, including Nurse Chukwuji-Ohanachum screaming and collapsing to the floor. CPR was not initiated immediately; instead, Olagunju sought the night manager, Alex Obamwonyi, on a neighboring ward. Obamwonyi determined Hugo had no pulse and feared starting resuscitation would compromise the crime scene, so he locked the door and called emergency services at 03:37. CPR began at 03:45, and Hugo was pronounced dead at 04:41.

Torres-Pena was seen walking the corridor before dawn without trousers, which the coroner noted were likely soaked in blood.

Hugo’s family expressed shock at the