NHS staff 'slept and falsified records' as patient was strangled to death on mental health ward

NHS staff slept, used their phones and falsified patient monitoring records on the night a man was strangled to death by a fellow patient on a mental health ward, an inquest has found.

Hugo Flint-Cahan, 34, was killed in the early hours of January 3, 2023, while receiving treatment at Newham Mental Health Centre in east London.

Mr Flint-Cahan had spent six months at the facility when he was attacked by fellow patient Rolando Torres-Pena, 22, on Topaz ward.

Senior Coroner for East London Graeme Irvine returned a narrative conclusion of unlawful killing contributed to by neglect.

He recommended four staff members be referred to their professional regulator and urged the Metropolitan Police to revisit its investigation.

CCTV showed Mr Flint-Cahan wandering the corridor before he was last captured alive at 1.22am.

At 1.31am, a neighbouring patient emerged from his room apparently disturbed by something and looked along an empty corridor.

No staff were visible, with this believed to have been around the time Mr Flint-Cahan was beaten and strangled.

Nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju remained behind a closed staffroom door, while nursing assistant Anthony Onuh had been sleeping in a therapy room for two hours.

Despite Mr Flint-Cahan having already been attacked, an observation log falsely recorded at 2am that he was awake in his bed.

Mr Onuh acknowledged to the coroner that he had completed the record without checking where patients were.

Shortly before 2am, Torres-Pena was captured on CCTV without trousers, which the coroner noted had been removed because they were drenched in blood.

Mr Flint-Cahan was not discovered until 3.19am, almost two hours after the attack.

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Mr Olagunju did not immediately begin CPR or raise the alarm, instead leaving to find night manager Alex Obamwonyi on another ward.

Mr Obamwonyi told the inquest he detected neither breathing nor a pulse but locked the room to preserve the scene because he believed resuscitation would be futile.

Paramedics were not called until 3.37am, with CPR beginning at 3.45am. Mr Flint-Cahan was pronounced dead at 4.41am.

Torres-Pena later pleaded guilty at the Old Bailey to manslaughter by diminished responsibility and was handed an indefinite hospital order.

Mr Flint-Cahan's father, William, said his son's death was "preventable had the level of care been as it should have been".

His brother Jolyon, an NHS doctor, described the "litany of failures, both incompetence and dishonesty, that pervaded the care of both patients" as "harrowing".

The coroner also condemned recurring failures involving the East London NHS Trust, describing evidence of the same problems across multiple deaths as "ground hog day".

Local coroners had issued 29 Prevention of Future Deaths notices involving the Trust over the previous 12 years, including warnings over falsified observation records.

Dr David Bridle, Chief Medical Officer at the Trust, said it was deeply sorry to the family and described the conduct identified by the coroner as "wholly unacceptable and do not reflect the standards, values or behaviours we expect".

The Trust said it would use the findings to strengthen its patient safety work.

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