Patient unlawfully killed at Newham mental health centre

Hugo Flint-Cahan, 34, was unlawfully killed at the Newham Mental Health Centre, an inquest has concluded. The senior coroner for East London, Graeme Irvine, found that neglect by staff contributed to his death. The ruling follows evidence presented at the inquest detailing how staff on duty on the night of the attack on 3 January 2023 were asleep, using their phones, and falsifying patient records.

Mr Flint-Cahan was being treated at the centre, run by the East London NHS Trust (ELFT), when he was fatally attacked by fellow patient Rolando Torres-Pena, then 22. Mr Torres-Pena pleaded guilty to manslaughter on the grounds of diminished responsibility at the Old Bailey and was given a hospital order without time limit.

Failures in patient care

The inquest heard that on the night of the attack, two nurses and a nursing assistant were on duty on the Topaz ward, an inpatient unit for men with acute mental health issues. CCTV footage showed that nursing assistant Anthony Onuh was asleep in a therapy room for two hours. Nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in the staff room with the door shut. The observation log for the ward falsely indicated that Mr Flint-Cahan had been checked at 02:00, when he was not in his bed. Mr Onuh admitted to the coroner that he had completed the form without checking on patients.

Nurse Chukwuji-Ohanachum told the coroner she was going to the therapy room to sleep during an unauthorised two-hour break. CCTV also showed her and another member of staff walking past with blankets around the time Mr Onuh was seen emerging from the therapy room with his bedding.

Mr Flint-Cahan was discovered at 03:19 by nurse Olagunju, nearly two hours after the attack. He did not attempt CPR or raise the alarm immediately, instead seeking out the unit's night manager, Alex Obamwonyi, who was on a neighbouring ward. Mr Obamwonyi told the inquest he thought it was too late to start CPR and wanted to preserve the crime scene. Emergency services were called at 03:37, with CPR commencing at 03:45. Mr Flint-Cahan was declared dead at 04:41.

Repeated warnings to the Trust

Graeme Irvine, the Senior Coroner for East London, described the evidence as being like "ground hog day", with repeated errors heard in relation to patient deaths. Over the past 12 years, coroners have sent at least 29 Prevention of Future Deaths (PFD) notices to the Trust. These notices are issued when a coroner identifies problems that could lead to further deaths if not addressed. Analysis of these reports by the BBC revealed that in more than half of cases, there was a failure to properly assess patient risk. Poor communication and falsified records were also repeatedly highlighted.

A 2021 report by the coroner warned of a "culture of impunity" at the Trust where inaccurate record-keeping was tolerated. Further reports in 2024 and 2025 continued to highlight missed observations and falsified records, despite assurances from the Trust. Concerns have also been raised about delays in emergency responses and staff administering CPR incorrectly.

Hugo's father, William Flint Cahan, described the staff's failures as "complacency" and a lack of care, stating his son's death was "preventable had the level of care been as it should have been." His brother, Jolyon Flint-Cahan, an NHS doctor, called the "litany of failures, both incompetence and dishonesty" harrowing.

Next steps

The East London NHS Trust has stated that it has addressed some of the issues raised and is launching an investigation into the staff involved. The coroner recommended that four members of staff be referred to their regulator and that the Metropolitan Police review their investigation into the events of that night. The Trust has been contacted for further comment.