Staff slept, falsified records during NHS patient killing — SkimNews
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- Hugo Flint-Cahan, 34, was strangled by fellow patient Rolando Torres-Pena, 22, at Newham Mental Health Centre on 3 January 2023; Torres-Pena pleaded guilty to manslaughter on grounds of diminished responsibility and received a hospital order without time limit.
- Nursing assistant Anthony Onuh admitted to the coroner he slept for two hours in the therapy room and filled out observation forms without checking where patients were, while two nurses — Rosemary Chukwuji-Ohanachum and Raji Olagunju — were in the staff room with the door shut despite patients wandering the corridor.
- Senior Coroner Graeme Irvine delivered a narrative conclusion finding Hugo was unlawfully killed with neglect contributing, recommended four members of staff be referred to their regulator, and asked the Metropolitan Police to review their investigation into the night.
- Night manager Alex Obamwonyi told the inquest Hugo wasn't breathing when he arrived but locked the room door rather than starting CPR, saying he thought it was too late and wanted to preserve the crime scene; Hugo was attacked around 01:31, discovered at 03:19, and declared dead at 04:41.
- East London NHS Trust has received at least 29 Prevention of Future Deaths notices over 12 years, with more than half citing failures to assess patient risk and multiple reports flagging falsified observation records — including a 2021 coroner's warning of a 'culture of impunity' at the Trust.
- Rethink Mental Illness head Brian Dow called for a national patient safety register, saying 'we have been here before' with falsified records, while Hugo's brother Jolyon Flint-Cahan — an NHS doctor — called the 'litany of failures, both incompetence and dishonesty' harrowing.
Why it matters: The inquest exposes a recurring pattern at East London NHS Trust: 29 Prevention of Future Deaths notices over 12 years with falsified observation records repeatedly flagged — yet Hugo Flint-Cahan still died from preventable failures in one night. Rethink Mental Illness is now pressing for a national patient safety register to hold trusts accountable when repeated warnings go unheeded.
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